CommonApplicationForm

DepartmentofHigherEducation,GovernmentofOrissa p g ,
Theapplicationformshouldbefilledin CAPITALLETTERS onlyandinapplicant'sownhandwriting.

ForDHEuseonly FORMNO.

forAwardofScholarship(CAFAS)

1.NameoftheScholarship appliedfor

2.Scholarship Code Affixselfattested(on thefront)recentcolour the front) recent colour passportsize photographhere.Don't staple.

3.College/InstitutionDetailswhereadmissionissecuredduring2009 (a)Name ( ) (b)Location (d)District (f)College/Inst.RollNo. (c)City (e)State (g)Council/Univ.Regd.No.

(h)CollegeCode(forGeneralCollegesofOrissa) 4. Fullnameof theAPPLICANT 5. Personaldetails oftheApplicant a. Caste[puttick( )whicheverisapplicable] ST D SC / M M OBC/SEBC / Y Y Y Oth. Y

b. Religion(usecode) d. Sex(M/F) d S (M/F)

c. DateofBirth D e. Nationality N ti lit

f MotherTongue f. M th T

6. Fullnameof FATHER 7. Fullnameof MOTHER 8. Profession& occupationof FATHER 10. CorresepondenceAddress a. HouseNo. c. PostOffice e. Tehsil g. State i. Telephone(withSTDCode) j. MobileNumber 11. PermanentAddress(Itmaynotbefilledup,ifPermanentAddressissameasCorrespondenceAddress) a. HouseNo. a House No c. PostOffice e. Tehsil g. State 12. Fullname& addressof b. b Street/Village d. Block/ULB f. District h. PINCode 9 Profession& occupationof MOTHER b. Street/Village d. Block/ULB f. District h. PINCode

theGUARDIAN (Ifparentsarenotalivepleasegiveguardian'sname&address) a. HouseNo. c. PostOffice e. Tehsil g. State i. Telephone(withSTDCode) j. MobileNumber 13. IfapplyingforScholarshiptoChildrenofSchoolTeachers(STC),thenpleasegivethefollowinginformation Ifprofessionofeither/bothparentsisteachinginGovt./Aidedschoolsasperitemno.8&9above,pleasewritename& a. NameoftheSchool b. Street/Village d. Block/ULB 14. IstheapplicantaHosteller?[puttick( )whicheverisapplicable]
(Ifyes,attachBoardercertificatefromconcernedauthority)

b. Street/Village d. Block/ULB f. District h. PINCode

c. PostOffice e. District Yes No Rs.

15. Annualincomeofparentsfromallsources
(Attachincomecertificate/incomecertificateandaffidavit,fromappropriateauthority,ifapplicable)

16. Particularsofexaminationspassed Sl# Name&Addressofthe School/College/Institution Nameofthe ExaminationPassed

Yearof Board/ UniversityName Passing Yearof Entry Yearof Exit Max. Mark Mark Secured

17. IfapplyingforP.G.levelMerit(PM)/MeritcumPoverty(PP)Scholarship,pleasegivethefollowinginformation a. NameoftheHons.Subjecttakenatundergraduatelevel b. MarksecuredinHons.Subject c. MaximumMarks

18. IfapplyingforTechnical/ProfessionalScholarship(TG&TM),pleasegivethefollowinginformation a. Nameoftheentranceexamination c. Yearoftheentranceexamination e. Nameofthecourseadmittedinto f. Dateofadmission D D / M M / Y Y Y Y g. Durationofcourse b. RollNumber d. RankSecured(ST/SC/GEN/Women)

19. a. Istheapplicantinreceiptofanyotherscholarship?[puttick( )whicheverisapplicable] f h S h l hi b. Ifyes,nameoftheScholarship b If c. AmountofScholarshipperAnnum 20. a.

[puttick( )whicheverisapplicable]

Yes

No

d. Datefromwhichreceived
Yes

DD/MM/YYYY No

Whethertheapplicanthasappliedforanyotherscholarshipduring2009?

b. Ifyes,nameoftheScholarship

c. Dateofapplication

21. BankAccountdetailsoftheapplicant(onlyNationalisedBankAccountmaybegivenforelectronictransferof a. AccountNumber c. NameoftheBank d. BranchName e. BranchCode

DeclarationbytheApplicant
I,Sri/Ms./Smt.............................................................................son/daughter/wifeof.....................................................dohereby declarethatallinformationgivenabovearetruetothebestofmyknowledge&belief.Iwillabidebyallrulesand regulationofthescholarshipscheme,ifselected.Iamnowpursuing.............................coursein .............................................................................................College/Institution.Iamnotinreceiptofanyscholarshipforthis coursenorshallreceiveanyotherscholarshipduringthecourseperiod.
Date Place .. ..

FullSignatureofApplicant

StudentshipCertificatebytheHeadoftheInstitution
Certified that Sri/Ms./Smt. ................................................................................... has been admitted in to this institution on .......................... as a regular student in the course ....................................... during the academic session,, 200910 bearing Roll g g g No. .......................... The above information furnished by the applicant are true to the best of my knowledge and based on records. His/Her rank in the Entrance Test conducted by ........................................................ is ................................ on the basis of whichhe/shehasbeenadmittedintothisInstitution. Thisapplicationiscountersigned. This application is countersigned
SignatureoftheHeadofthe Institutionwithdate&seal. Essentialenclosures 1 OriginalResdentialCertificateinproformaasinAppnedixA 2 Originalincomecertificateofparentsfromemployerand/orappropriateauthority(applicableforJP,SP,PP,STC,TG&TM) 3 Incomeaffidaivtofparents/guardianinproformaasinAppendixB(applicableforTG&TM) 4 Attestedcopyofmarksheetoflastqualifyingexamination(e.g.10thBoardmarksheetforJM&JP) 5 Attestedcopyofpasscertificateof10thStd.Exam/+2Exam/DegreeExam,whicheverisapplicable. 6 ServicecertificateasinAppendixCfromHeadmasterofthschool&countersingedbyDI/CIofshools,(applicableforSTC) 7 BoardercertificateiftheapplicantapplyingforSchoalrshiptoTeacher'sChildren(STC)isaHosteller 8 AttestedcopyofrankcardissuedbythechairmanofOJEE/AllIndiaTest.(applicableforTG&TM) 9 Selfattseted(onfront)passportsizephotographtobepastedatthefrontrightcorneroftheCAFAS. 10 AttestedcopyoftheBankPassBookshowingnametheapplicant&accountnumber.

Appendix -A

Format for Permanent Residential Certificate

I certify that Sri/Smt./Miss ____________________________________________________________ Son/daughter/ward of ______________________________________________________is a permanent resident of the State of Orissa. He / She belongs to village / Town / Lane __________________________ P.O.__________________________P.S._______________ Block _____________ Tahsil __________________ District __________________ of Orissa. This certificate is issued for his / her higher studies.

Signature of the applicant

Signature and seal of the Revenue Officer Date

Note: - Revenue officer means the Chief Officer in change of the Revenue Administration of the District, Sub-Division or
Tahasil and includes Addl. District Magistrate, Sub-Divisional Officer, Tahasildar and Addl.Tahasildar.

Appendix B

Format of Affidavit for Annual Income of Parents

Declaration regarding the annual income of the parent /husband / wife for the year ending on 31stMarch, 2009 for award of ______________________________Scholarship during the year 2009-10. I/We, Sri/Smt._____________________& Sri/Smt._______________________son/ husband / wife of Sri/ Smt./ Kumar____________________________________________resident of__________________________P.O.__________________________ P.S ______________________ Tahasil________________________Dist.__________________in the State of _________________ do solemnly declare that my/our son/daughter/wife _________________________________ who is pursing __________________ Course at_____________________________________Institution is an applicant for award of________________________Scholarship for the session 2009-10. My / Our annual income is not more than Rs._________/-(Rupees__________________) only from all sources as stated below. If it is proved to be false in future, I/we declare solemnly that, I / we shall pay back the scholarship amount received by him / her and legal action under Section 181 of the Indian penal code shall be taken against me / us. Sl No. 1 2 3 4 Sources of income Income from landed property Income from Service as salary Income from business / rented house Income from other sources , if any Total Grand Total Rs. Rs. Rs. Rs. Rs. Father Mother Rs. Rs. Rs. Rs. Rs. Guardian Rs. Rs. Rs. Rs. Rs. Husband Rs. Rs. Rs. Rs. Rs.

Full signature of parent /husband/wife

Appendix- C

Format of Service Certificate from Employer

(certificate from the Head of the Institution where the father/mother of the candidate is employed) Certified that, Sri/Smt.. father/ mother of Sri/Smt. who is an applicant under the scheme is working as a teacher in the Primary/Middle/Secondary/ Higher Secondary section in my school. Certified also that the school is recognized by the State Government.

School Seal
Countersignature & seal of the DI/CI of Schools

Signature of the Head Master Name of the School

Appendix D

Proforma for Renewal of Scholarship

Annual progress report for the year... 1) 2) 3) 4) 5) Sl No. 1 Name of the College/Institution. Name & branch of the Drawee Bank Branch code No. . College/Institution Account No Name of the Scholarship .. Year and Courses in which Admitted 3 Batch of award 4 Class to Year of Percentage Period/ Remarks which promotion of Marks Year of promoted Secured renewal required 5 6 7 8 9

Name of the Scholarship Holder 2

Certified that the aforesaid awardees have been promoted to the next higher class & eligible for renewal of the Scholarship mentioned at Sl No. 5 above during the session-2009-10. An amount of Rs.. (Rupees ..)only sanctioned /placed during the last Financial Year vide DHE(O) letter No. .dt has been fully utilized /paid to the concerned awardees. The attested copies of mark sheets in respect of above awardees are enclosed herewith.

Date.. Signature & Seal of the Head of the Institution