POSTMATRIC SCHOLARSHIP FOR MINORITY STUDENTS

FRESH SCHOLARSHIP – 2010-11 APPLICATION FORM
Affix a Colour Photo size3.5x4.5cms

Self Attest
STUDENT NAME
PARENT/GUARDIAN NAME PERMANENT ADDRESS

PIN
Date Month Year

6
FEMALE PARSI

DATE OF BIRTH
RELIGION( ) CHRISTIAN

1
MUSLIM

GENDER ( ) SIKH

MALE
BUDDHIST

Name of the Community Permanent Community Certificate Number B C C/M
(Dist Code) (Taluk Code) (VillageCode) (Certificate Number)
Community Certificate or Self Declaration Affidavit on Non-Judicial Stamp Paper of Rs.10/- by the Parent-Guardian of student that he/she belongs to the Minority in Tamil Nadu notified by the Government of India)

ANNUAL INCOME OF THE PARENT/GUARDIAN Rs.
(Income Certificate from Designated Revenue Authority or Self Declaration Affidavit on Non-Judicial Stamp Paper of Rs. 10/- by the Parent/Guardian about annual Income to be given in the format enclosed

Student/Father/Mother’s Savings Account Number Name of the Bank

Branch Code Total Marks obtained out of / / / / % of Marks

Record of Performance – 2009-10
Examination Passed 10/+2/ Diploma/ UG/PG Year Board/Institute & University’s Consolidated Mark sheet No. Main &Ancillary Subjects

Scholarship sought for 2010-11 Name of the Class/Course studying Duration of Course Years Details of Annual Course Fee: Admission Fee Rs. Tuition Fee Rs. Exam Fee Rs. Date

Year I/II/III Academic Year 2010 to Library Fee Rs. Other Non Refundable Fee Rs. Total Course Fee Per annum Rs. Signature of the Student

1

. . . . . . . . . . For Employed Parents/Guardians have to furnish income certificate from the employer along-with affidavit on Non-Judicial Stamp Paper of Rs. . . . . . . . . . . . . . . . . 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 by law. . . . . . . . . . . . . . . . . . . . . . . . . . . . . it is found to the satisfaction of the sanctioning authority of State Government of Tamil Nadu that the information given by me is false or if I violate the terms and conditions of the scholarship. . . … . . . . .10/.. . . . .4)Proof of Permanent Residence 5) Savings Bank Account Details Information to be furnished by the Head of School/College/Institute It is certified that the information filled in the above mentioned application by Shri/Kumari . .10/. . . .DECLARATION I. . . . . . . .10/-. . I shall abide by the terms and conditions for the sanction of Postmatric Scholarship and undertake that if at any stage. iv) Date: Place Signature of the Correspondent/Principal/Dean/Registrar with Official Seal * Strikeout whichever is not applicable. . . hereby declare that the informations given in my application are correct and I am not availing any other scholarship for this purpose from any other source. Date : Place: Signature of the student Encl: Attested copies of certificates of 1) Educational qualifications 2) Community Certificate from Revenue Department or Self Declaration of Affidavit on Non/Judicial Stamp Paper of Rs. . . . . . . . . ii) iii) He/She is a hosteler/day scholar of the School/College/Institute He/She has been promoted from to or passed all subjects in the semester/non-semester examination(s) and secured 50% of marks in the academic year . . .. . . . . The scholarship will be disbursed after satisfying the yardstick of attendance in the current year of the student.Course for the academic session . . in our School/College/Institute is correct. . . . . . Who is admitted in .by the Parent/Guardian 3)Latest Income Certificate: obtained from Revenue authority not below the rank of Deputy Tahsildar ( or) Income Declaration: For Self Employed Parents/Guardian: have to furnish Affidavit on Non-judicial stamp paper of Rs. S/o (or) D/o . 2 . . . . .

. (Parent/Guardian ) of .(Name of the Student) who is studying in . . . .. . . . . . . . . . . . . . . . . . . . . . . . all the benefits given to my son/daughter/ward under the scheme of “Postmatric Scholarship” for students belonging to the minority communities could be withdrawn and legal action as deemed fit. . . . . . . . . . . . . . . . Signature of Parent/Guardian Residential Address Date: -------------------------------------------------------------Specimen DECLARATION OF STUDENT’S COMMUNITY BY THE PARENT/GUARDIAN (on Non-Judicial Stamp Paper of Rs 10/-) I. . . . . . Signature Date (Father/Mother/Guardian) Residential Address 3 . . . . . . . . . . . . . . . . . . hereby declare that my annual income from all sources is Rs.Specimen SELF DECLARATION OF PARENT/GUARDIAN’S ABOUT INCOME (on Non-Judicial Stamp Paper of Rs 10/-) I. . .Std. . . . . . . . . . . . . . . .. . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (Parent/Guardian) of . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . (Name of the Student) who is studying in . . . . . . . . . . . . . . . . . declare that the above information given by me is true to the best of my knowledge to avail the benefits given to my son/daughter/ward and it is found that the information given by me is false. . . . . . . . the scholarship amount sanctioned could be withdrawn or recovered from me and legal action as deemed fit. . . . . . . . . . . . . . . . . . . . . . . I. . may be taken against me or my ward. . . . . . . .. . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . If any stage. (Name of theSchool) hereby declare that the community of my son/daughter/ward is . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . which is a minority community notifed by the Government of India. . .. . . may be taken against me or my ward. . . . . . . . . . . . . . .. . . . . . . . .. . . . . . . . . . . . . . . . . .only). . . . .(Rs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . it is found that the information given by me is false/not true. . . . . . . . .

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