DEPARTMENT OF INTERMEDIATE EDUCATION

APPLICATION FOR AWARD OF SCHOLARSHIP UNDER “PRATHIBHA” SCHEME Category opted Marks secured / Total Note :- NO REQUEST FOR THE CHANGE OF COMMUNITY / CATEGORY WILL BE ENTERTAINED AFTER SUBMISSION OF APPICATION FORM. THE AWARD OF THE SCHOLARSHIP WILL BE CONSIDERED ON THE APPLIED. AS COMMUNITY CATEGORY UNDER WHICH IT IS APPLIED. AS COMMUNITY CATEGORY IS NONTRANSFERABLE. IT SHOULD BE CAREFULLY SELECTED WHERE CANDIDATE IS ELIGIBLE UNDER MORE THAN ONE CATEGORY FROM AMONG SC / ST / LBC / PH / MINORITY / OC / WOMEN.

INSTRUCTIONS TO THE APPLICANT : 1) 2) 3) 4) Read carefully the instructions before filling the form. On the performance in Intermediate Public Examination / CBSE-XII / ICSC-XII / CBSE Under which quota Prathibha Scholarship – Desired: SC / ST / BC / Minority / PH/ OC / Women. To qualify for the “Prathibha” Scholarship, the student should have secured 1st Class with a minimum of 60% of aggregate marks in the proceeding Intermediate Public Examination. If any information is found to be incomplete, the application will be rejected and no appeals will be considered thereafter. If particulars furnished subsequently are found to be false, the scholarship will be cancelled and the amount paid will be recovered with interest and additional penalty will also be imposed. The application should be endorsed and forwarded by the Head of Institution where the applicant is presently studying. All necessary attested certificates are to be appended to the application form. Affix recent passport size photograph in the space provided in the application form. The photograph should be attested by the Head of the Institution. The application shall reach the Director of Intermediate Education, Opp: Latha Talkies, Nampally, Hyderabad – 500 001, Andhra Pradesh, super scribing on the cover as.

5) 6)

7) 8) 9) 10)

“Application for “PRATHIBHA” AWARDS – 2000” Recent passport size photograph attested by the Head of the Institution

1.

Name of the student in full (Use capital letters) Father’s Name (In Capital Letters) Name of the Guardian (If father is not alive) Sex (Male / Female) Date of Birth Particulars of Examination Passed

:

2.

:

3.

:

4. 5. 6.

: : : I.P.E / CBSE X/XII/ICSC- XII/X (Strike off whichever is not applicable)

a) b) c) d) e) f)

Group (Science/Humanities) Register Number Month and year of passing Total Marks secured Percentage of marks secured (copy of Marks memo is to be enclosed) Whether passed in 1st Class in one attempt or not

: : : :

7.

College/Institution from which the above examination passed (Full address of the college with pin code) SC/ST/Minority/BC/P.H. (necessary certificate is to be enclosed)

:

8.

9.

a)

Present Postal Address with Pin code :

b)

Permanent Postal Address with Pin code

:

Particulars of Higher study presently persuing : 10. Name of the college (with full postal address with Pin Code No. Name of the course and year presently studying (IIT/MBBS/BE/Btech/B.D.S/ BSc./B.Com./B.A. etc.,) a)

:

11.

:

12.

For renewals only: State the year in which the applicant has been selected for the Award : Percentage of marks obtained by the Candidate in the qualifying exam. (copy of the memo of marks should be enclosed) : Scholarship sanction proceedings No. With date and the amount in the case Of renewals :

b)

c)

13.

Whether the candidate is in receipt of any other scholarship, if yes: a) Name of the Scholarship b) Amount of the Scholarship

: :

14.

Whether the student opts for “Prathibha” Scholarship and is he/she prepared to forego The scholarship which he/she is presently Enjoying (student is entitled to the above Only one scholarship) :

Yes / No

Date :

Signature of the Candidate

DECLARATION TO BE SIGNED BY THE CANDIDATE AND PARENT / GUARDIAN

The particulars furnished in this application are true and correct. Further, we declare that, the information furnished if found to be false or suppressed at any time, we shall refund the entire scholarship amount to be Government of Andhra Pradesh, together with interest and penalty imposed in lumpsum.

Signature of Parent / Guardian

Signature of the Candidate

CERTIFICATE (to be issued by the Head of the Institution where he/she now studying after IPE) It is certified that Mr/Mrs. …………………………………………… S/o, D/o …………. Is a bonafide student of this Institution who is studying / ………………………….. (course & year) during the academic year ……………………… with admission No & Dt…………………. The particulars furnished by the candidate are correct as per the records of this office. I have verified the following original certificates and attested the copies which are enclosed herewith : 1. 2. 3. 4. 5. Marks Memo & Pass certificate (Inter /CBSE / ICSC) Prathibha Award Certificate (For renewals only) Case/Minority category certificate (Except O.C) Physically Handicapped Certificate issued by D.M.H.O./Authorised Arthopedician. Marks Memo of the proceeding examination passed (applicable for renewals only)

Place : Date :

Signature of the Head of Institution (office seal) (the college in which the student is presently studying)