ANNEXURE A Application for award of scholarship to students with disabilities (All information should be given either in English or in Hindi only) Photograph 1. Name ___________________________________________________ (Passport size) 2. Address ______________ ___________________________________ duly attested by the institute _________________________________________________________ __________________State ___________________Pin_____________ 3. Date of Birth _________________________ 4. Sex(M-Male, F-Female) 5. (i) Type of disability (Please enclose disability certificate) (OH-Orthopadically Handicapped, HH-Hearing Handicapped, VH-Visually Handicapped, C4-Other disabilities e.g. Cerebral Palsy, Low vision, Mental Retardation etc.) (ii) Percentage of disability _______________% 6. Educational Qualification Examination Passed Name of the Institution Name of board/ University the Major Subjects Aggregate marks obtained & % thereof* Class/ Division Matric/ Secondary Sr. Secondary/ Intermediate Graduation Others * In case of grades, mention equivalent % of marks and also enclose conversion formula 7. Family Income per annum (in Rs.)_______________(enclose Income Certificate) 8. (i) Course applied for (complete name) ___________________________ (ii) Academic Session ________________ (iii) Duration _______________ (iv) Date of Admission _____________________ 9. Name and address of the institution where course will be under-taken. 10. Whether hosteller or a day scholar (If hosteller please specify whether provided by the institution or own arrangement and address of the hostel)_________________________________________________________________ _________________________________________(Enclose certificate) 11. Details of Scholarship/Stipend/financial assistance being received for the same course (if any). 12. Any other information applicant wishes to provide. I hereby declare that information provided above is true to my knowledge and I am aware that providing wrong information will make me liable to legal action and recovery of scholarship amount. Name & Signature of the applicant Date: Place: Recommendation of the institution TO BE FILLED BY INSTITUTE 1. Certified that Sh./Ms. ___________________________________ is studying course of ______________________________(Diploma/Degree and above) a professional/ nonprofessional course and is presently studying in the following year of the course (Tick whichever is applicable): The duration of the course is ......... 2. The information furnished above by the student is in order and correct as per records of the Institution. 3. The student is receiving scholarship/financial aid/stipend from ___________________/not receiving any scholarship/financial aid/stipend from any other source as per records of the Institute 4. General conduct of the student is satisfactory/ unsatisfactory (please strike out whichever is not applicable) Signature & Name of Head of Date: ________________ Institution /Registrar/Dean Place: ________________ Seal of the Institution
