ECSS- Educational Crisis Scholarship Support

An initiative of HDFC Bank

Education is the investment our generation makes in the future-Mitt Romney

APPLICATION FORM

1 Personal Details
Student Category

University

Name of the student

Gender
Date of Birth (DD-MMM-YYYY)
Current Class

Specialization (If any)

% marks or Grade obtained in the last class
Father's / Guardian's Name
Mother's Name
Please state the relationship in case of
Guardian

2 Contact Details
Residential Address (please write the complete
postal address)

Landmark
City / District
State
Pin code

Male

Affixrecentcolor
photoofthestudent
andsignacrossthe
photograph

Phone # (Landline with STD)

Phone # (Mobile)

3 Family Details
Name of the member

Relation with the child Age

Education

Occupation

0.00

Total Annual Income

No. of dependant members
(No.of non-earning members)
Type of family (Please tick any one option) Single

Socio-economic
Details
ocio-economic Details
4S
A Destitute/orphan

Annual Income

No

If Yse,Specify Year of Death:

Single parent child

No

If Yes,Specify Year of separation/death:

Differently able child

No

If Yes,Specify:

Parents/child/siblings suffering / under treatment for life threatening

illness

NO

If yes, please
Specify name of
disease/illness:
Year of detection:
Undergoing treatment at:

Crisis such as disaster/accident/loss of job,etc.

NO

if Yes,Year of occurrence :

B Total Annual income of the family from all the sources is

Less than Rs. 50000

Between Rs.50000 to Rs.1.5 lakhs
Between Rs.1.5 lakhs to Rs.2 lakhs
Between Rs.2 lakhs to Rs.3 lakhs
Rs. 3 lakhs & above

Specify..

C Nature of dwelling/house

Select

Own

5 Institute Details
A

Name of the school/College/University

Type of College/University

Recognized by

Annual School/College/University Fee

Complete address of School/college/

university

Private

(please write the complete postaladdress)

Landmark

City/District

H
I
J

State
Pin Code
Phone No. (with STDCode)

6 Name in which the cheque needs to be drawn (Please ensure that the full name of the Institution is correctly mentioned))

(Eg. ABC Education Trust/XYZ College of Technology,etc.)

A

Name of the School/College/Trust/

Society/Foundation

7 Previous scholarship

A
B
C

Have you applied for ECSS Scholarship before?

If so, which year?
Have you received the ECSS scholarship before ?

NO
Specify 2014

NO

If so, which year?

Specify

Is any other sibling (own brother/sister) applying for the

Scholorship ?

if Yes, Name of the sibling (own brother/sister)

2014

YES

8 Briefly describe the reason of applying & impact of scholarship on the child's education

9 Please provide two references (Referees cannot be friends or relatives)

Name of the person

Tel. no. (with STD

Code)

Occupation
(e.g Businessman)

Relationship with the applicant

Email Id (if any)

(Mandatory for Manual submission)

I (Guardian Name)______________________________________________certify that the information in this application is accurate and true and further, I agree to
all the conditions .
Signature/ Thumb impression

_______________________________________________________

Date __________________
Place

__________________

Reccommended by __________________
School/College/University authority signature __________________

10 Nearest HDFC Bank Branch

Name of the nearest HDFC Bank branch Branch Code
Branch Code

Branch Verification
Required only for manual submission

ensure that the following documents are securely attached and put a tick () wherever applicable.
Students last academic years report card

Income proof from employer (Annexure IA). In case of self employment, self attested income declaration. (Annexure IB)
Verification certificate from school (Annexure IIA) duly stamped and signed by school authoirty
OR
Verification certificate from college/university (Annexure IIB) duly signed and stamped by college/university authority

Any 2 Address Proof (Aadhar-UIAID Card)

Ration Card

Passport

Electricity Bill

Phone bill

Submission: The Branches are requested to send the Application Forms at the following address:
Corporate Social Responsibility, HDFC Bank,
Alpha Building, I-Think Techno Campus, 9th Floor,
Kanjurmarg-East,
Mumbai-400042, Maharashtra,
India
Branch Name:________________________________
Location:__________________________
Date:_____________________

Signature of Branch Manager_________________________

Name of Branch Manager____________________________
Employee Code___________

Stamp