For official use only
Sl No of application Year Course Whether approved

Student ID: Roll No: 87


Affix a self attested passport size photograph

1.Studnet Name 2.Father's name/Husband's name 3.Mother's name 4.Mobile No 5.E-Mail 6. Domicile State/UT (State/UT which the student belongs to) 7. Address for correspondence: House No. & Street Detail City/Town/ Village & P.O. District State Pincode

: ANSARI FIRDOS : Abdul Latif : Madeena : 8793084686 : : Maharashtra

H.No.811/10,Hafiz Nagar Rose Medical, Diwan shah Bhiwandi -421302 Thane Maharashtra 421302

8. Permanent address(please enclose residential certificate from concerned state government authority): House No. & Street Detail H.No.811/10,Hafiz Nagar Rose Medical, City/Town/ Village & P.O. Diwan shah Bhiwandi -421302 District State Pincode Thane Maharashtra 421302 05-Jun-1992 : Female

9. Date of birth (Please enclose certificate) : 10. Whether male or female 11. Religion 12. Nationality
13.Aadhar No:

: Muslim : Indian

Printed Date: 15-Sep-12

Page 1 of 7

If so the name of authority which has recognized the College(or)School: (vii) To which university is it affiliated/does it have deemed university status : Printed Date: 15-Sep-12 Page 2 of 7 .421302 (iii) Telephone no: (iv) Fax no: 225957 (v) E-mail address: 225437 princy_gmmwc@yahoo. Details of educational qualifications from matriculation/SSLC/SSC onwards (Please enclose certificates attested by a gazetted officer): Examination University/Board/College (or) passed School/Council of Examination Year of Passing 2009 Division Percenta /Class/ ge marks Grade 54. MOMIN WOMEN'S COLLEGE .M. (vi) Is the college/school recognized. Basis of admission in professional/technical course (whether on the basis of qualifying competitive examination or on other grounds. G. .A( BACHOLER OF ARTS ) 3 2012-2013 N 15.Rais High School Campus. Please give details): 16.M .E.Bhiwandi. Details of course for which scholarship is being sought: Name of the course: Duration of course Academic year Hosteller B.Thana Road. Details of college/school: (i) Name of the college/School where admitted: (ii) Address of college/school: K.13.5000 Main Subjects HSC 14.SOCIIETY'S.

00 3600. library fee.00 3200. Details of bank account of student: Name of the payee (as in the bank accounts) Name of the Bank Full Address District Bank Branch State Pin code Branch Code number Bank Account Number Bank Account Number in words Type of bank Account(Saving/Current) MICR code of the Bank Mode of Electronic transfer available in the Bank – ECS/RTGS/NEFT/CBS/code number (if any). In case parent/guardian are employed. 22000 (specimen form of declaration of annual income is given at Annexure which is to be signed by the parent/guardian of the student and enclosed alongwith the application. Total Annual course fee: 3600.00 (Break up of course fee such as tuition fee.00 19.20. 1. other than refundable deposits): Sl. 2 Tuition Fee Admission Fee Total Item Annual fee 400. examination fee etc.17. For renewal of scholarship: Name of examination passed Year Marks Obtained Full marks % of marks 18.No. income certificate from the employer may also be enclosed) 3198806998 CENTRAL BANK OF INDIA KUMBHAR WADA bHIWANDI Printed Date: 15-Sep-12 Page 3 of 7 . Annual Income of parent/guardian of the student: Rs.

21. it is found to the satisfaction of the sanctioning authority in the Ministry of Minority Affairs that the information given by me is false or if I violate the terms and conditions of the scholarship.affidavit on non-judicial stamp paper and income certificate from the employer (iv) Proof of permanent residence (v) Receipt in acknowledgment of scholarship in the previous year duly countersigned by the head 22. Documents enclosed with the appplication: (i) One copy of passport size photograph with signature (ii) Attested certificates of educational qualification as filled up in para 11. may be cancelled and the entire amount of scholarship will be refunded by me or recovered from me. (iii) I shall abide by the terms and conditions for sanction of the Post-Matric based scholarship. (iv) I undertake. (iii) Income declaration . Signature of the candidate Date: Place: Printed Date: 15-Sep-12 Page 4 of 7 . Declaration : (i) I hereby declare that the information given above is correct. the scholarship sanctioned to me. (ii) I am not availing any other scholarship for this purpose from any other sources. apart from liability for such penal action as warranted by law. that if at any stage.

M.M. D/O Shri Abdul Latif who is admitted in B.S Signature of head of the institution / college With official seal Date: Place: Printed Date: 15-Sep-12 Page 5 of 7 . Verification/information to be furnished by the Head of institution/college: It is certified that the information filled in the above mentioned columns by Shri/Smt/Kumari ANSARI FIRDOS S/O. For Renewal of scholarship: Details of bank account of institution/college (For deposit of course fee): (i) Name of the payee (as in the bank accounts) : Principal G.III year for the academic session 2012-2013 in K. college is correct.21. G.E.M .SOCIIETY'S. MOMIN WOMEN'S COLLEGE .A( BACHOLER OF ARTS ). He/she is a hosteler/day scholar of the college.Momin Womens College (ii) Name of the Bank : BANK OF MAHARASHTRA (iii) Bank Branch (Full address) : State District Pin (iv) Branch Code number : (v) Bank Account Number : 20133859927 (in words_________________________________________________________) (vi) Type of bank Account : (vii) MICR code of the Bank : (viii) Mode of Electronic transfer available in the Bank – ECS/RTGS/NEFT/CBS/code number (if any).

without facing any competitive examination. of the concerned State Govt/UT administration. on the basis of a competitive examination ii) Students. who have got admission in a recognized college to pursue technical/professional courses.2 lakh per annum from all sources. deptt. will also be eligible for scholarship. v) A student residing in a particular State/UT will be entitled for scholarship under the quota of that State/UT only irrespective of his place of study. such students should have not less than 50% marks at higher secondary/graduation level. dealing with minority welfare. How to Apply Applications in the prescribed format may be submitted to the Secretary of the. The student must submit their applications to the state which he/she belongs to and not to the state where the institution where he/she is studying. through the institutions where the students are pursuing technical/professional courses.Eligibility criteria (i) Students. who have got admission in a recognized college to pursue technical/professional courses. However. Printed Date: 15-Sep-12 Page 6 of 7 . iii) A scholarship holder under this scheme will not avail any other scholarship/stipend for pursuing the course. iv) The annual family income of the beneficiary/parent or guardian of the beneficiary should not exceed Rs. Selection of these students will be done strictly of merit. is located.

A( BACHOLER OF ARTS ) III year hereby declare that my annual income from all sources is Rs.Pune411001 Printed Date: 15-Sep-12 Page 7 of 7 ./ 22000. Signature Residential Address Date: (Father/Mother/Guardian) H.Central Building.Annexure DECLARATION OF FAMILY INCOME I Abdul Latif (Father /Mother /Guardian) of ANSARI FIRDOS (Name of student) who is studying in B.No.it is found that the information given by me is false/not true.all benefits given to the student under the scehme of PostMatric scholarship based to the student belonging to minority communities could be with dran and legal action as deemed fit. Diwan shah Bhiwandi -421302 Thane Maharashtra 421302 [This is a draft format which the State government/UT administration may modify/amend to suit legal requirements] Postal Address: Director of Higher Education.00 if at any stage.811/10.Hafiz Nagar Rose Medical. may be taken against me or my ward.Maharashtra State.