SCHEME OF POST-MATRIC SCHOLARSHIP FOR STUDENTS BELONGING TO THE MINORITY COMMUNITIES FORMAT OF APPLICATION
FOR OFFICIAL USE ONLY Sl. No. of application Year Course Whether approved
[ To be filled up by applicant. ] Part – I 1. A. 1. FRESH OR RENEWAL? Full name (in block letters)
Affix a selfattested passport size photograph
Surname First Name Middle name 2. Father’s name:
3.
Mother’s name:
4.
State/UT of domicile
5.
Address for correspondence:
Name House no. Mohalla/Street City/Town/Village & P.O. District State Pin Code Tel No., including mobile number, if any.
e-mail ID, if any
6.
Address of the parents.
Name House no. Mohalla/Street City/Town/Village & P.O. District State Pin Code Tel No., including mobile number, if any.
e-mail ID, if any 7. Permanent address:
Name House no. Mohalla/Street City/Town/Village & P.O. District State Pin Code Tel No., including mobile number, if any.
e-mail ID, if any 8. D Date of birth (Please enclose certificate) D M M Y Y Y Y
9. Male 10.
Whether male or female: Female Nationality:
11.
Religion:
12.
Details of educational qualifications from matriculation/ SSLC/ SSC onwards (Please enclose copies of certificates attested by a gazetted officer) University/Board/ Institute/Council of Examination Main subjects Year of passing Percentage marks Division/ Class/ Grade
Examination passed
13. (i) (ii) (iii) (iv)
Details of course for which scholarship is being sought: Name of class/course Duration of class/course Academic year Class/course last attended/academic year (v) Total Marks obtained and percentage in last examination : : : : :
14.
Details of school/college/institute, including residential ones: (i) Name of the school/ college/ institute : where admitted (ii) Address of school/ college/ institute :
15.
For renewal of scholarship Name of examination Year passed
Marks obtained
Full marks
% of marks
16.
Total Annual course fee: Rs.……………../(Break up of course fee such as tuition fee, library fee, examination fee etc. other than refundable deposits) S.No. 1 2 3 4 5 6 Item Annual fee
Total 17. Day Scholar or Hosteller:
Yes No (i) Whether staying in the hostel run by the school/college/institute (ii) If not and staying as an outstation student as paying guest or in rented accommodation in towns/cities which are not the places their parents resides, then the complete postal address of the landlord of the paying guest/rented accommodation may be given. Name of landlord Rent per Month Full postal address
P I Telephone/ Mobile no. of landlord. 18. (i) (ii) (iii)
N
Details of bank account of student: Name of the payee (as in the bank accounts) Name of the Bank Bank Branch (full address ) _____________________________________
_____________________________________ _____________________________________
State District Pin (iv) (v)
e_____________________________________ t_____________________________________ n_____________________________________
Branch Code number ______________________________________ Bank Account Number ______________________________________ (in words ____________________________________________________) (vi) Type of bank Account _____________________________(Saving/Current) (vii) MI CR code of the Bank _ _____________________________________ (viii) Mode of Electronic transfer available in the Bank ECA/RTGS/NEFT/CBS/ code number (if any). 19. Annual Income of parents/guardian of the student: Rs._______
(Declaration of annual income is to be given in the prescribed format given below and is to be signed by the parents/guardian of the student and enclosed along with the application. In case parents/guardian are employed, income certificate from the employer be enclosed). 20. (i) (ii) (iii) Documents enclosed with the application Self-attested passport size photograph with signature. Attested copies of certificates of educational qualifications as mentioned up in para 12. Income declaration – affidavit on non-judicial stamp paper worth Rs. 10/- for selfemployed parents/guardian or income certificate from the employer for employed parents/guardian. Proof of permanent residence on non-judicial paper worth Rs. 10/-. Minority community declaration – affidavit on non-judicial stamp paper by the student that he/she belongs to any one of the minority communities notified by Central Government Declaration: I hereby declare that the information given above is correct. I am not availing any other scholarship for this purpose from any other source. I shall abide by the terms and conditions for sanction of the Post-matric Scholarship. I undertake that if, at any stage, it is found to the satisfaction of the sanctioning authority in the concerned State Government/Union Territory Administration that the information given by me is false or if I violate the terms and conditions of the scholarship, the scholarship sanctioned to me, may be cancelled and the entire amount of scholarship will be refunded by me or recovered from me, apart from such penal action as warranted by law.
(iv) (v)
21. (i) (ii) (iii) (iv)
Date: Place:
Signature of the student
Part–II [to be filled up by the Head of the school/ college/ institute] 22. Details of school/college/institute including residential ones: : : : : : :
(i) Name of the school/college/institute where admitted (ii) Address of school/college/institute (iii)Telephone no (iv) Fax no (v) E-mail address (vi) If a private institute, is the school/ college/ institute recognized? If so, the name of authority which has recognized it
23. Verification/information to be furnished by the Head of school/ college/institute: (i) It is certified that the information filled in the above mentioned columns by Shri/Kumari________________s/o / d/o Shri ________________ who is admitted in________________________________course for the academic session_______________in_____________school/college/institute is correct. (ii) He/she is a hosteller/day scholar of the school/college/institute.
OR
He/She is staying as paying guest/in a rented accommodation at the address given at para 16 as per office records. (iii) He/She is a fresher admitted in the school for academic year _________
OR
He/She has been promoted from _________ to __________ in the academic year __________. 24. Details of bank account of school/college/institute (For deposit of course fee):
(i) Name of the payee (as in the bank accounts) (ii) Name of the Bank (iii) Bank Branch (full address ) _____________________________________
_____________________________________ _____________________________________
State District Pin
e t n
_____________________________________ _____________________________________ _____________________________________
(iv) Branch Code number ______________________________________ (v) Bank Account Number ______________________________________ (in words ____________________________________________________) (vi) Type of bank Account _____________________________(Saving/Current)
(vii) MI CR code of the Bank _ _____________________________________ (viii)Mode of Electronic transfer available in the Bank ECA/RTGS/NEFT/CBS/ code number (if any).
25.
For Renewal of scholarship
It is certified that the above mentioned student has passed the____________________________examination for_____________(year) and has obtained ______________% of marks. It is also certified that the student has not changed the course of study and/or the school/ college/ institute of the study for which the scholarship was originally awarded/has changed the course of study and/or school/ college/ institute with prior approval of the State Government (please strike out which is not applicable).
Date: Place:
Signature of Head of the school/ college/ institute With official seal
DECLARATION OF PARENTS’/GUARDIAN’S INCOME (Specimen) I………………………………………………….……….……(Parents/Guardian) of
……………………….. …………………………(Name of Student) who is studying in …………………………………….. hereby declare that my annual income from all sources is Rs………….(in figures)
Rupees…………………………………………………….…………only (in words).
If any stage, it is found that the information given by me is false/not true, all benefits given to the student under the scheme of “Post-matric scholarship for students belonging to minority communities” could be withdrawn and legal action as deemed fit, may be taken against me or my ward. Signature Date: (Father/Mother/Guardian) Residential Address 