PRE-MATRIC SCHOLARSHIP FOR MINORITY STUDENTS Affix a passport size

colour photo
Application Form
3.5 X 4.5 cm

FRESH - 2010-11
Self Attest
1. Student Name : (in block letters)
2. Father / Guardian Name
3. Mother Name :
4. Permanent Address :

P I N
Phone / Cell No.
Day Month Year Gender (3)
5. Date of Birth
M F
6. Religion : (3) Muslim Christian Sikh Buddhist Parsi
7. Community : ( Copy of certificate to be enclosed )
Dist. Code Taluk Code Village Code Permanent Community Certificate No:
B C C/M
Declaration: Affidavit on non-judicial stamp paper of Rs. 10/- by the parent/guardian of the Student that he/she
belongs to any one of the Minority Communities notified by Central Govt. to be furnished)

8. Annual Income of Parent / Guardian of the Student:

(Latest income certificate obtained from designated Revenue Authority or Self Declaration of annual income of Parent /
Guardian to be given in the prescribed format (Specimen enclosed) on non-judicial-stamp-paper of Rs.10/-)

9. Record of performance in 2009-10 :

Name of the School Class / Roll No. Total Marks obtained % of marks

10. Details of Class in 2010-11 for which scholarship is being sought for :
Name of the School Class now studying Roll No.

11. Total annual course fees paid by the student:

Maintenance fees Admission fees Tuition fees Other (to be specified) Total
Rs. Rs. Rs. Non-refundable fees (Rs. ) Rs.

12 Details of bank account of student/ Father/ Mother/Guardian:

Name of the payee Bank a/c number Name of the bank Branch Code Bank Telephone No.

Bank Address:-…………………………………………………………………………………………………………………..
………………………………………….State:………………………District:……………………Pin Code:…………………
13. Declaration:
I, ……………………………… hereby declare that the information given in my application are correct and 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 Pre-
matric Scholarship. I undertake that if at any stage, it is found to the satisfaction of the Government of Tamil Nadu that the
information given by me is false or if 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/recovered from me, apart from such penal action as warranted.

Signature of the student

Date: (Signature/Thumb impression of the student’s parent/guardian

Place: ( for Students of Class I to V)