FORM OF APPLICATION FOR GOVERNMNET SCHOLARSHIP FOR BLIND, DEAF, AND DUMB AND ORTHOPAEDICALLY HANDICAPPED STUDENTS (To be submitted through the principal / head of Institution to the District Social Welfare Officer, concerned) (Incomplete application or applications received after the stipulated date may not be entertained) (the last date for submission of the application is ________ To The Director of Social Welfare Meghalaya Shillong Sir, I beg to apply for a scholarship for /Blind/Deaf/Deaf and Dumb/Orthopaedically Handicapped Person. The course for which I propose to study is _________________________________ ________________________________________ for which I have joined __________________ _____________________________________school/college/institution/university. If I am awarded a scholarship, I agree to abide by the Rules governing its award, I shall also infom the Director of Social Welfare if I take any employment or if I am awarded any other scholarship so long as I held the present scholarship. I further state that, I am (I) blind/ deaf/ deaf and dumb/ orthopaedically handicapped (ii) the income of my parents or guardian is less than Rs. 6,000 (Rupees six Thousand) per annum and (ii) that I am a permanent resident of Meghalaya state. Yours faithfully Signature of the Candidate Instructions to candidate to fill in the form 1. According to Rule 2, a totally blind person has been defined as " (a) total absence of sight (b) Visual acquity not exceed 3/60 or 10/200 (snellon) in the better eye with correcting lenses" and the deaf are those in whom the sense of hearing is non-functional for the ordinary purpose of life. A deaf and dumb person is one who is deaf as defined above and also does not have the power of speech. An orthopaedically handicapped person has been defined as " one who has a physical defect or deformity or has partially or totally lost any limb of the body thereby causing and interference with normal functioning of the bones, muscles and joints. A certificate from a Civil Surgeon or a Gazetted Officer of the Meghalaya Medical Service will therefore be necessary to the effect that the candidate is blind/deaf/ deaf and dumb/orthopaedically handicapped as defined in Rule 2. 2. A declaration (in the form attached at Appendix 'B') should be filled in by the parent /guardian of the candidate regarding his/her annual income. This declaration should also be attested by the head of institution in which the candidate is studying or by some responsible person such as Gazetted Officer, Local MLA, MP, and MDC. 3. If the proof of date of date of birth is not available, a certificate stating the approximate age of the candidate should be obtained from the Medical Officer certifying the blindness deafness or orthopaedically handicapped of the candidate and should be attached to the application. The Applicant Particulars 1. Name of the applicant with fathers name and surname ( in Block letters) 2. Date of birth (according to Christian era) 3. The applicants Domicile 4. Present address 5. educational attachment reached at the time of applying the scholarship 6. year in which the applicant first joined the school/college/institution which he she has now joined and age on 1st June of the year 7. Course of study for which he she has joined the school/college/institution 8. Duration of the course 9. Place of birth ( Village and district) 10. Full name and address of the school/college/institution from which the applicant passed his/her last examination giving the village and district where the school/college/institution is situated. 11. Full name and address of the school/college/institution from which is studying giving the Village post Office and District where the School/College/institution is situated. 12. Year in which passed the last examination. 13. Marks obtained in the last examination passed (attested copy of marksheet should be attached) 14. Whether at present the holder of any scholarship, if so, give details. 15. Whether suffering from any physical handicapped other than blindness/deafness or orthopaedic disability. 16. Parents and Guardians name in full and address 17. Domicile of the parent or Guardian Relation Occupation Annual income from all sources 18. Whether Hostler or non hostler ( If Hostler, name of the hostel maybe given ) Date. ...... Signature of applicant Certificate of the Principal/Headmaster of the institution in which the candidate is studying I certify that Shri/Smti ...................Has joined this college /School /Institution on ..........and has been a bonifide student of my institution since the date My Institution is recognised by the Meghalaya State Government Vide __________________ (Quote authority) The date of his/her birth as entered in the College/School/Institution Register is ......... My remarks regarding his/her progress, conduct, etc, are as under: 1. Character: 2. Ability: 3. Regularity of attendance: 4. Health 5. General Recommendation Principal/Headmaster of College/ School/Institution (with seal) Appendix 'A' CERTIFICATE TO BE SIGNED BY THE MEDICAL OFFICER EXAMINING THE CANDIDATE 1. I, Civil surgeon/medical Officer ........................ have examined Shri/Smti ....................and certify that he/she is so blind as to be unable to perform any work for which eyesight is essential. 2. I, Civil surgeon/medical Officer ........................ have examined Shri/Smti ....................and certify that he/she is so deaf that his/her sense of hearing is non-functional for normal functioning of life. 3. I, Civil surgeon/medical Officer ........................ 4. I, Civil surgeon/medical Officer ......................... have examined Shri/Smti ....................and certify that his/her orthopaedic condition is as below- Extent and character of a limb if any .......................... ................ weakness of paralysis of any muscle .......... ............................nature and extent of disablity Is the disability accompanied by any pain and mental defiency ? 1. I, further certify that shri/smti 3. . I, ............. is physically and mentally fit apart from his/her orthopaedic disability to undertake studies. The orthopaedic disability is not of a nature to interfere with his/her normal education manner. His /her age is according to his/her own statement ............... years and by appearance ................ years Place ............... Signature ............... Date ............... Designation ............... (This Certificate is to be given when the candidate has no proof of his/her date of birth). APPENDIX 'B' DECLARATION OF INCOME Note - 1. The declaration must be signed by the parent or guardian of each candidate. The Principal/headmaster of the Institution will then forward to the director of social welfare along with the application. The parent or guardian must make a separate declaration for each candidate. Note - 2. Each declaration must be authenticated by the Headmaster/Principal or by some responsible person such as a gazetted Officer, Local MLA, MP, MDC. 1. The Details of age/Scholarship received, etc., furnished by my son/daughter/ward (name ................. of class ........of the .......... (College/school/institution) are correct. 2. I, declare that the above candidate is my son/daughter/ward 3. I, guardian/parent named .................. of the above candidate ............. of the village for town ............... of the district ...................... Declare that the annual income from all sources is not more than Rs. ................. And there are ................. members in the family dependent on me. 4. I, also undertake to refund whatever amount by way of scholarship which my son/daughter/ward has received on the strength of this statement made by me, if my income exceeds the limit prescribed by Government. I am aware that the statement with regard to my income and thereby to claim a scholarship when the same is not admissible to my son/daughter/ward is an offence for which penal proceeding will be taken against me if; I fail to refund the amount on demand. I, agree that the government may recover the same for my property as arrear of land revenue. Date on which signature or thumb impression signature or thumb impression of the Was appended parent/guardian of the pupil ATTESTATION CERTIFICATE I .......................................... of the Village or town ................ of district ............. attest the signature/thumb impression of the person named above as having been made in my presence Place............. Date............. Signature /thumb impression
