Common Application Form
Department of Higher Education, Government of Orissa p g ,
The application form should be filled in CAPITAL LETTERS only and in applicant's own handwriting.
For DHE use only FORM NO.
for Award of Scholarship (CAFAS)
1. Name of the Scholarship applied for
2.Scholarship Code Affix self attested (on the front) recent colour the front) recent colour passport size photograph here. Don't staple.
3. College / Institution Details where admission is secured during 2009 (a)Name ( ) (b)Location (d)District (f) College/Inst. Roll No. (c) City (e)State (g) Council/Univ. Regd. No.
(h)College Code (for General Colleges of Orissa) 4. Full name of the APPLICANT 5. Personal details of the Applicant a. Caste [ put tick ( ) whichever is applicable] ST D SC / M M OBC/SEBC / Y Y Y Oth. Y
b. Religion (use code) d. Sex (M/F) d S (M/F)
c. Date of Birth D e. Nationality N ti lit
f Mother Tongue f. M th T
6. Full name of FATHER 7. Full name of MOTHER 8. Profession & occupation of FATHER 10. Corresepondence Address a. House No. c. Post Office e. Tehsil g. State i. Telephone (with STD Code) j. Mobile Number 11. Permanent Address (It may not be filled up, if Permanent Address is same as Correspondence Address) a. House No. a House No c. Post Office e. Tehsil g. State 12. Full name & address of b. b Street/Village d. Block/ULB f. District h. PIN Code 9 Profession & occupation of MOTHER b. Street/Village d. Block/ULB f. District h. PIN Code
the GUARDIAN (If parents are not alive please give guardian's name & address) a. House No. c. Post Office e. Tehsil g. State i. Telephone (with STD Code) j. Mobile Number 13. If applying for Scholarship to Children of School Teachers (STC), then please give the following information If profession of either/both parents is teaching in Govt./Aided schools as per item no. 8 & 9 above, please write name & a. Name of the School b. Street/Village d. Block/ULB 14. Is the applicant a Hosteller? [ put tick ( ) whichever is applicable]
(If yes, attach Boarder certificate from concerned authority)
b. Street/Village d. Block/ULB f. District h. PIN Code
c. Post Office e. District Yes No Rs.
15. Annual income of parents from all sources
(Attach income certificate/income certificate and affidavit, from appropriate authority, if applicable)
16. Particulars of examinations passed Sl# Name & Address of the School/College/Institution Name of the Examination Passed
Year of Board / University Name Passing Year of Entry Year of Exit Max. Mark Mark Secured
17. If applying for P.G. level Merit(PM)/MeritcumPoverty(PP) Scholarship, please give the following information a. Name of the Hons. Subject taken at under‐graduate level b. Mark secured in Hons. Subject c. Maximum Marks
18. If applying for Technical/Professional Scholarship (TG & TM), please give the following information a. Name of the entrance examination c. Year of the entrance examination e. Name of the course admitted into f. Date of admission D D / M M / Y Y Y Y g. Duration of course b. Roll Number d. Rank Secured (ST / SC / GEN / Women)
19. a. Is the applicant in receipt of any other scholarship? [ put tick ( ) whichever is applicable] f h S h l hi b. If yes, name of the Scholarship b If c. Amount of Scholarship per Annum 20. a. [ put tick ( ) whichever is applicable]
Yes
No
d. Date from which received
Yes
DD/MM/YYYY No
Whether the applicant has applied for any other scholarship during 2009?
b. If yes, name of the Scholarship
c. Date of application
D
D
/
M
M
/
Y
Y
Y
Y
21. Bank Account details of the applicant (only Nationalised Bank Account may be given for electronic transfer of a. Account Number c. Name of the Bank d. Branch Name e. Branch Code
Declaration by the Applicant
I, Sri/Ms./Smt. ............................................................................ son/daughter/wife of ..................................................... do here by declare that all information given above are true to the best of my knowledge & belief. I will abide by all rules and regulation of the scholarship scheme, if selected. I am now pursuing............................. course in ............................................................................................. College / Institution. I am not in receipt of any scholarship for this course nor shall receive any other scholarship during the course period.
Date Place …………………….. ……………………..
Full Signature of Applicant
Studentship Certificate by the Head of the Institution
Certified that Sri/Ms./Smt. ................................................................................... has been admitted in to this institution on .......................... as a regular student in the course ....................................... during the academic session,, 2009‐10 bearing Roll g g g No. .......................... The above information furnished by the applicant are true to the best of my knowledge and based on records. His/Her rank in the Entrance Test conducted by ........................................................ is ................................ on the basis of which he/she has been admitted into this Institution. This application is countersigned. This application is countersigned
Signature of the Head of the Institution with date & seal. Essential enclosures 1 Original Resdential Certificate in proforma as in Appnedix‐A 2 Original income certificate of parents from employer and/or appropriate authority (applicable for JP,SP,PP,STC,TG & TM) 3 Income affidaivt of parents/guardian in proforma as in Appendix‐B (applicable for TG & TM) 4 Attested copy of marksheet of last qualifying examination (e.g. 10th Board mark sheet for JM & JP) 5 Attested copy of pass certificate of 10th Std. Exam/+2 Exam/Degree Exam, whichever is applicable. 6 Service certificate as in Appendix‐C from Headmaster of th school & countersinged by DI/CI of shools, (applicable for STC) 7 Boarder certificate if the applicant applying for Schoalrship to Teacher's Children (STC) is a Hosteller 8 Attested copy of rank card issued by the chairman of OJEE/All India Test. (applicable for TG & TM) 9 Self attseted (on front) passport size photograph to be pasted at the front right corner of the CAFAS. 10 Attested copy of the Bank Pass Book showing name the applicant & account number.
Appendix -A
Format for Permanent Residential Certificate
I certify that Sri/Smt./Miss ____________________________________________________________
Son/daughter/ward of ______________________________________________________is a permanent resident of the State of Orissa. He / She belongs to village / Town / Lane __________________________ P.O.__________________________P.S._______________ Block _____________ Tahsil __________________ District __________________ of Orissa. This certificate is issued for his / her higher studies.
Signature of the applicant
Signature and seal of the Revenue Officer Date
Note: - Revenue officer means the Chief Officer in change of the Revenue Administration of the District, Sub-Division or
Tahasil and includes Addl. District Magistrate, Sub-Divisional Officer, Tahasildar and Addl.Tahasildar.
Appendix – B
Format of Affidavit for Annual Income of Parents
Declaration regarding the annual income of the parent /husband / wife for the year ending on 31stMarch, 2009 for award of ______________________________Scholarship during the year 2009-10. I/We, Sri/Smt._____________________& Sri/Smt._______________________son/ husband / wife of Sri/ Smt./ Kumar____________________________________________resident of__________________________P.O.__________________________ P.S ______________________ Tahasil________________________Dist.__________________in the State of _________________ do solemnly declare that my/our son/daughter/wife _________________________________ who is pursing __________________ Course at_____________________________________Institution is an applicant for award of________________________Scholarship for the session 2009-10. My / Our annual income is not more than Rs._________/-(Rupees__________________) only from all sources as stated below. If it is proved to be false in future, I/we declare solemnly that, I / we shall pay back the scholarship amount received by him / her and legal action under Section – 181 of the Indian penal code shall be taken against me / us. Sl No. 1 2 3 4 Sources of income Income from landed property Income from Service as salary Income from business / rented house Income from other sources , if any Total Grand Total Rs. Rs. Rs. Rs. Rs. Father Mother Rs. Rs. Rs. Rs. Rs. Guardian Rs. Rs. Rs. Rs. Rs. Husband Rs. Rs. Rs. Rs. Rs.
Full signature of parent /husband/wife
1
Appendix- C
Format of Service Certificate from Employer
(certificate from the Head of the Institution where the father/mother of the candidate is employed) Certified that, Sri/Smt…………………………………………………………………………….. father/ mother of Sri/Smt…………………………………………………………………………………………. who is an applicant under the scheme is working as a teacher in the Primary/Middle/Secondary/ Higher Secondary section in my school. Certified also that the school is recognized by the State Government.
School Seal
Countersignature & seal of the DI/CI of Schools
Signature of the Head Master Name of the School
Appendix – D
Proforma for Renewal of Scholarship
Annual progress report for the year………………………………………... 1) 2) 3) 4) 5) Sl No. 1 Name of the College/Institution…………………………………………. Name & branch of the Drawee Bank…………………………………… Branch code No. …………………………………………………. College/Institution Account No………………………………… Name of the Scholarship ……………………………………….. Year and Courses in which Admitted 3 Batch of award 4 Class to Year of Percentage Period/ Remarks which promotion of Marks Year of promoted Secured renewal required 5 6 7 8 9
Name of the Scholarship Holder 2
Certified that the aforesaid awardees have been promoted to the next higher class & eligible for renewal of the Scholarship mentioned at Sl No. 5 above during the session-2009-10. An amount of Rs………….. (Rupees ……………………………… ………………………………………..)only sanctioned /placed during the last Financial Year …………… vide DHE(O) letter No. ………….dt…………… has been fully utilized /paid to the concerned awardees. The attested copies of mark sheets in respect of above awardees are enclosed herewith.
Date……………….. Signature & Seal of the Head of the Institution
2 