FRESH APPLICATION FORM FOR GOVERNMENT OF INDIA POST-MATRIC SCHOLARSHIPS TO SCHEDULED CASTE/SCHEDULED TRIBE STUDENTS FOR THE YEAR 20 - 20 . N.B. The students who are reading outside the state, will submit their application to the ST & SC Development Department through the Head of the Institution. While submitting application form for sanction of Post-Matric Scholarship, the SC/ST students must submit the documents/ papers along with the application form as per checklist at the bottom. In absence of any of the document as mentioned in the checklist, his/her application will summarily be rejected without intimation. Last date for submission of application form will be published in the leading dailies. Applicant must affix a passport size photograph with his/her signature thereon and it should be attested by the Head of the Institution To The Principal / Sub-Collector/DWO/Registrar................ PART-A (To be filled in by the applicant in neat and clear handwriting) 1. Name in full (in capital letters) : Shri/Kumari/Smt 2. Date of Birth (in Christian era) : 3. (a) Caste and Sub-Caste (S.C.) : (b) Tribe and Sub-Tribe (S.T.) 4. Religion : 5. State where permanently settled State : District/Subdivision/Block/Police Station : Full Permanent Address : 6. Father's/Husband's name in full : 7. Whether parent are employed : Yes/No If yes, whether: - (a) Govt. Sector/ Private Sector : Monthly emolument (Salary Certificate from the employer must be attached) 8. Whether the applicant is in employment : Yes/ No If yes, whether: - (a) Part-time/ Full time : Monthly emolument 9. Whether in receipt of scholarship under the scheme or any other scheme in the previous year? If yes, indicate- (i) Name of the scholarship scheme : (ii) Course of study for which scholarship was given : (iii) Name of the institution in which the scholarship was awarded. : 10. (a) Whether the applicant has applied for or receiving any other scholarship/stipend or remuneration in this current session. (b) Whether the applicant has applied for Post-Matirc Scholarship as a student of any other institution during the session under this scheme 11. (a) Whether in receipt of ad-hoc grant during 20-20 : (b) Amount of ad-hoc grant received : 12. Particulars of examination taken commencing with the Matriculation or equivalent examination (Please attach attested copies of certificates, mark sheets. Any break in educational career should be indicated in remarks column) 2 Name of Examination Institution and University/ Board Yearwhich taken in Whether passed or not, if passed state division and percentage of marks Remarks 13. Post matric scholarship applied for the year:- 14. (i) Course of study for which the scholarship is now desired : (ii) Duration of course : (iii) Date of admission : (iv) Tentative Month/Year/ of final examination : 15. Whether residing in the hostel of the institution. : (i) If yes, give its (Hostel) Name & Address : (ii) Date of joining & certificate of the warden with seal and signature must be attached I/We hereby declare that I/We have read the regulation of the Scheme and agree to abide the terms and conditions of award. I/We certify that the statements made in the application are correct and if any of them is found to be incorrect by the authority, his decision will be final and binding on me/us. I/We undertake to refund to the said authority on demand the entire amount of scholarship received by me/us or overpaid to me/us failing which the said authority may recover the amount from me/us through whatever means it deems proper. (i) Signature of the applicant........... (ii) (a)Signature/left/right hand thumb impression of parents Date......... legal guardians............ Place.......... (b) Full name in capital letters............ (c) Relationship to student............. N:B- Signature of Applicant duly attested by Head of Institution. PART-B (To be filled in by the Head of the Institution where the applicant is studying) (i) The statement made by the applicant in Part-A are correct to the best of my knowledge and the caste certificate has been checked. : (ii) Character, conduct and attendance of the applicant (general review) 3 : (iii) Whether you recommend the applicant for the award of a scholarship : (iv) Duration of the course which the applicant is studying in your institution : : (v) Date of commencement of the current academic session of this course. : (vi) Exact date on which the applicant joined that course/class this year : (vii) Likely date, month and year on which the annual examination of the current session will be over (including practical) : (viii) (a) Is the applicant exempted from payment of tuition fee : Yes/No (b) If yes, please indicate whether exemption is for full or half tuition : (ix) (1) whether the applicant is residing in the hostel of the institution or an approved hostel. : Yes/No (2) If the applicant is residing in a hostel, please indicate, if he/she is entitled to- : (a) Free boarding : (b) Date of joining in the hostel/ approved, hostel : (x) (a) Whether the ad-hoc grant has been disbursed to the applicant during 200 -200 : Yes/No (b) Amount of ad-hoc grant disbursed during 200 -0 : Rs.......... (xi) Name of the nearest branch of State Bank of India or the Government Treasury through which the payment of Scholarship desired............................ Certified that this Institution is affiliated to ..............University/ Board and is recognized by the Government of India/State Government of ......... The applicant is studying...........course in this institution and the minimum qualification required for admission to that course is a pass in the........ ...examination. I undertake that the Scholarship amount in respect if the applicant if and when placed at my disposal will be disbursed by me for the specific purposes for which it is given and the accounts will be regularly rendered to the authority which awarded the scholarship. In case, the applicant leaves institution or otherwise discontinues the studies or accepts any other regular scholarships/ stipend the fact will be immediately reported to the said authority and payment of scholarship to the applicant will also be discontinued. The amount not disbursed and lying with the institution on account of maintenance charges, fees, etc. will also be refunded to the Government account. No.......... Signature of the Head of the Institution ........ Place......... Name in Capital letter................. Date........ Address................... ...................... ...................... Seal of the Institution N.B.- (1) Stamped signature will not be accepted. (2) No application will be entertained unless it is recommended through a forwarding letter by the Head of the Institution. 4 PART-C (To be filled in by Head of the Institution where the applicant is studying) Details of the non-refundable compulsory fees (excluding hostel rent and other incidental charges) payable by the applicant during the current year to the institution. The applicant is required to pay compulsory fees (excluding hostel rent and other incidental charges) amounting to Rs. .............. to this institution for the current year from ........... to ........... as per details given below : Particulars of all non-refundable compulsory fees payable by the applicant Rate Amount actually payable by the applicant to the institution Remarks Rs. P. Rs. P. Tuition Examination Games Library Medical Total Any other compulsory non-refundable fees paid by the applicant to the institution be indicated here. No fee should be given without details. Signature of the Head of the Institution Seal CHECK LIST Documents to be attached : Please put a 'X' in the Box alongside 1. Passport size photograph in the appropriate box of the application form with his/her signature thereon and the photograph must be attested by the Head of the Institution. 2. Caste Certificate from the competent authority. 3. (a) Income certificate from the concerned authorized authority/ persons. (b) Salary Certificate from the employer if parent are employed. 4. Income declaration of parents/guardians from all the sources on non-judicial stamp paper. 5. Part-'B' of the application form countersigned by the Head of the Institution. 6. Forwarding letter by the Head of the Institution.
