Specimen application form 2012 13
- 1. YES /NO e. Nationality: Indian P I N - i. Gender (M-Male/F-Female) / / ( D D / M M / Y Y Y Y ) (Muslim/Christian/Parsi/Buddhist/Jain/Sikh) 3. Total Annual Course fee in Rs. (Do not include refundable deposits) Tution Fees Dev. Fees Other Fees Total a. Name of the Bank : b. Full Address P I N c. Branch Code d. A.c No e. IFSC code of the Bank Branch 5. Annual Income of Parent / Guardian of the student : Rs. ___________________________ 2 1 Minorities Development Department Year of PassingUniversity / Board Institution / Council of Examination Percentage of marks HSC g. Tel. No. (With STD) (Specimen form of declaration of annual income and minority status on Rs. 10/- non judicial stamp paper/court fee is given at Annexure I which is to be signed by the studnet and parent /Guardian of the student. In case parent / guardian are employed, income certificate from the employer may also be enclosed) c. Mothers' Name ( As appeared in the SSC Marksheet ) b. Fathers' / Husbands' Name Examination Passed d. Domicile State : 2. Qualification Details ( SSC Onward) f. Address for correspondence k. Religion j. Date of Birth h. E-Mail GOVERNMENT OF MAHARASHTRA Application Form for Minority Scholarship Scheme for All courses after H.S.C.(Arts,Commerce,Science,etc.) For Office Use Only SL. No. of Application Year Course Recommended for Scholarship ? a. Full Name: 3 4 4. Details of Bank account of Students 1. Personal Details Total in words : Rs. ______________________________________________________________________________ FRESH / RENEWAL SSC SN Paste Latest Passport Size Color Photo with Signature. Do not Staple. 2012-13 1 / 2
- 2. 6. a.Course Name : b. Year of Study : a. b. Institute Address : P I N c. Telephone No. d. Fax No. e. Email Address : f. Is the college / institution recognized. ( Yes / No) g. h. Name of University / Board is it affiliated : 8. Documents to be enclosed with the application i) Attested certificates of educational qualification as filled up in para 2. 9. Declaration a b c Date : Place : Name ( Date : Place : Signature of the Head of Institution / 7. Name of the College / Institution where candidate has admitted : I undertake, if it is found 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 liability for such penal action as warranted by law. Institute Name : ii) Declaration of Family Income & Minority Community Status - affidavit on Rs. 10/- non-judicial stamp paper /court fee and income certificate from the employer, if any If yes the name of authority which has recognised the institutions : College with official seal. Signature of Candidate I shall abide by the terms and conditions for sanction of Scholarship for Minority Students for pursuing Technical & Professional Studies ( Proforma is filled by the Institute / College Head with official seal) It is certified that the information filled above by Shri / Smt. / Kumari _____________________________________ S/O. D/O, W/O Shri ___________________________ ____________________ who is admitted in course ______________ for the academic year-2012-13 in college is correct. iii) Proof of permanent residence ( Domicile Certificate / Ration Card/ Driving License / Electricity Bill/ Indian Passport/ Election ID/ Telephone Bill/ etc) 10. Verification of information to be furnished by the Head of Instituion / College : iv)Advance Receipt of Payment __________________________________) I hereby declare that the information given above is correct. v) Xerox copy of Candidate's bank account passbook. 2012-13 2 / 2