Download Application for fresh scholarship for the physically handicapped students

GCPP.-15S/10-2,OOO Cps. (G 12)-27-7-2005. GOVERNMENT OF PONDICHERRY ... SOCIAL WELFARE DEPARTMENT ==: Scholarship for the Physically HaDdicapped~ApplicatioD for Fresh Scholarship PART-I . (To be filled ID by the caodldate) . Nature of phy~ical handicap BlindjDeaf/OrthopaedicallyhandicappedJ. 2. Name in full (in block letters) Postal address to which communications are to be sent 3. .4~ (a) Arc you a citizen of India (b) Na~lvc place (c) Whether schedulcd caste/tribe S. Date .of birth (in Christian era) 6. (i) Name of the parent/guardian (ii) Profession (iii) Addre~s (iv) Relationship of guardian Monthly guardian of both tho parentsl 7. incomo 8. Please state if you are earning an Income: YesjNo (i) Tho source (ii) Tho monthly amount 9. (a, Particulars of all examination) passed 10 far : (b) Percentage of marks obtained in the last examination passed (mark list of the previous annual examination to be enclosed) !10. Have you cver received acholarship under this scheme? If yes, indicate (i) The course of study . (ii) .The period from which acholanhip was paid ! (Ifi) Referencc number, if any ~ 2 Please state whether you havo undorgone any training course at any training centre for adult blind/deaf approved by the Central/State' Government (i) Course of study for which scholarship is now desired (ii) Date of commencement of course (iii) Approximate date of termination of the course (iv) Dato of joiniDg the present standard in the course during the current academic year For Blind- Have you engaged II reader? If yes, please indicate (i) Amouut paid for month (ii) Date of engagement 14. Documents attached- (I) (ii) (iii) (iv) (v) I hereby dcclarc- (i) that I shall not accept any emoluments, scholarships, stipend or any other financial assistanCt' .or grant in any other form whatsoever, except exemption from tuition fees, from any other source during the tenure of this scholarship if awarded to mc under the above scheme. OR that I am in receipt of assistanCe to the tune of Rs. --from - ~nd i~ the event of award of scholarship. I undertake to refund it from the month, the scholarship is payable to me, to the source from where I have received it, and that during the tenUre of scholarship, if awarded. I shall not receive any o~her financial assistance, emoluments, scholarships, stipend or any grant in any form whatsoever, except the exemption from payment of fees. (ii) that the statements made in the application are true to the best of my knowledge and belief and that no material information having a bearing on selection has been can-.:elled or withheld. Counter signature of Gazetted Officer or Centralj State Government / M.P. / M.L.A. / Magistrate / Head of the. Inslitutio~. Signature or the candidate. Place Countersignature of the parent/guardian.Date 3 PART-II (To be filled in by the Head of Institution) 1. (a) Is the candidate enjoying free board and/or lodging facility or any other concession in kind? \ . (b) If so, indicate the monthly amount equivalent to the' concession : 2. Is the candidate residing in an hostel attached to school? If so. date from which residing I 3. For orthopaedically handicapped- 'i) (a) Is the candidate using any prosthetic appliances(s) and/or in any aid needed? : (b) If so, please indicate the nature for appliance, used : (ii) (a) Is the candidate using special transport to and from the Institution? I (b) If so, please indicate clearly the mode of transport and the approximate distance travelled daily. -4. For blind- Has the candidate engaged a reader? If so. the monthly amount paid to him/her and the date from which engaged? (i) Certified that the information given by the applicant in Part-I has been checked and fouod correct. tii) This Institution rocognised by the Government of and tho course of study is recognised by that Government. Signature of the Head of InstitutionPlace Date: Name (in block letters) : Designation : Address Pincodo (Seal of the Head of the Institution) .)4 Medical Certificate in Respect of Orthopaedically Handicapped Candidate . For tbc purpose of ~cbolarsh1p thc orthopaedically handicapped are thosc who havc physically defect or deformity which cause an' intcrfercnce with the normal functioning or bones, musclca and joints. Certified that I,Dr """"""""""""""" Registration No. , .."",..." have this ".".. day of """"'" 200 "'.'."".'" examined the applicant whose particulars arc given below and that hcJshe falls within the above definition. Name of the candidate Identification mark2. Sex 't Father's name S. Approximate age 6 (8) Nature of disability (Tick relevant from following list) POST-POLIO PARALYSIS, HAMIPLEGIA,QUADRAPLEGJA,MALUNITIED FRACTURE, NERVE PARALYSIS, UPPER EXTREMITY, LOWER EXTREMITY, LIMP, PAJNFUL SHORTENING, DEFORMITY, CONGENITAL ACQUIRED, ABOVE KNEE,BELOW KNEE, HIP, HEMIPELVECTOMY, SYMES, CHEOPARES, WRIST, FINGERS, BELOW ELBOW, ABOVE ELBOW, SHOULDERS, FORE QUARTER, UNILATERAL, BILATERAL. (b) Extent or disability. Estimate in percentage (Mc.Bride Scale) ON ANATOMICA;L, FUNCTIONAL, (PAnENTS ASSESSMENT, ] ASSESSMENT) ECONOMICAL BASIS MENTION AS PERCENTAGES. (c) Uso of appliance 1 8XAMINER'S(rIck relevant from following list) CALLIPER, CRUTCH, ABOVE KNEE, BELOW ,KNEE, PROSTHESIS, CANE, UNILATERAL, BILATERAL, ABOVE ELBOW, BELOW ELBOW, HEMIPELVECTOMY, SHOULDER, DIS.ARTICULA TION. (d) Any operation done or indicated (e) Photograph (Attested) (To show the nature of disability and any appliance if used) 7. Any other particulars to clarify the nature and extent of disability that the surgcon ml8~t like to point out.- Signa~ure of Orthopaedic SurgeonSignature of Candidate Place: Designation Date Office Stamp Address 5 SCHOLARSHIP FOR THE PHYSICALLY HANDICAPPED-INCOME. CERTIFICATE . bestI, .certify to the I of my knowledg~ and belief that the total combined income from all sourcr.$ of both the parents/ guardian of ThiI:u/Tmt./Selvi (Name of the candidate) resident of is Rs... (Rupees ) per annum. Sigftnre.oJ candidate ., Place: Signature Name (in block letters) : Designation Office stamp Note: It may be given by a Revenue Officer not below the rank of Deputy Tahsildar. DECLARATION TO BE GIVEN BY THE PARENT/GUARDIAN I, father/guardian of Thiru/Tmt./Selvi. ~ undertak~ to intimate to the Department of Social Welrare, PonJicherry, any change. in the above mentioned income that takes place at any time during the pendency of the scholar.hip. . Signature ProfessionPlace Postal address