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Application / Registration No.

( TF/13/05569 )


(To be funded out of Trust Fund for Empowerment of Persons with Disabilities) PART-A (To be filled up by candidate) 1. 2. 3. Name of the Candidate Name of the State Residential Address : ASHUTOSH KUMAR SINGH : UP : VILLAGE MASURAN,POST NARAYANPUR KALAN,TEHSIL KADIPUR,DIST. SULTANPUR, U.P. 228131 District : SULTANPUR State : UP Pin : 228131 4. Institutional Name & Address : KANPUR INSTITUTE OF TECHNOLOGY,KANPUR Address : A-1,ROOMA INDUSTRIAL AREA,KANPUR NAGAR U.P. 208001 District : KANPUR NAGAR State : UP Pin : 208001 M Sr. Secondary/ Intermediate U.P. BOARD OF HIGH SCHOOL & INTERMEDIATE EDUCATION B.TECH 4 Yrs. OH (Orthopaedically Handicapped) 50% PUNJAB NATIONAL BANK SULTANPUR KNIT KNIT,SULTANPUR U.P. 228018 3914001500091160 PUNB0391400 Page No..............

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Sex Educational Qualification Name of the Board/University Course in which Studying (current) Duration of Course Type of Disability Percentage of Disability Student Bank Detail Bank Name Bank Branch Name Bank Address Bank Account No. IFSC Code No. Academic records (Attach copy of Certificate and Marks Sheets- Matric & above ) Family Income Certificate / Proof of Annual Income (Criteria<= Rs. 300000 p.a) e.g. salary slip, last income tax assessment order Attested copy of Disability Certificate Course Fee receipt (if any) with break up of each Item duly paid during the academic session Hostel (Certificate should be submitted in original)

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*(Photo copies off the documents from S.No. 12 to 15 should be attested by the Gazetted officer) Signature (For Official use)

(i) Course in which admitted : (ii) Qualification required for the course : (iii) Marks obtained :

Annexure - A


(To be funded out of Trust Fund for Empowerment of Persons with Disabilities) PART - B Application for award of scholarship to fresh students with disabilities 1. Name : 2. ASHUTOSH KUMAR SINGH (as in Secondary/Senior Secondary certificate) Please paste you passport Address : VILLAGE MASURAN,POST NARAYANPUR size photo in KALAN,TEHSIL KADIPUR,DIST. SULTANPUR, this space. U.P. 228131 State : UP Tele no.(if any) : Date of Birth : 01 May 1993 Sex please specify (M-Male, F-Female) : M (i) Type of disability (Please specify) : OH (Orthopaedically Handicapped) [(1) Orthopaedically Handicapped, (2) Hearing Handicapped, (3) Blindness or Low Vision, (4) Other disabilities e.g. Cerebral Palsy, Mental Retardation Multiple Disabilities, Profound or Severe Hearing Handicapped] (ii) Disability Percentage : 50% (Please enclose an attested copy of the disability certificate) Educational Qualification Name of the Board/ Major Subjects Marks Marks Class/ University obtained % Division U.P. BOARD OF HIGH SCHOOL & Class VIII JIC,K.B.PUR,SULTANPUR SCIENCE,MATH,ENGISH 803 67 2/1 INTERMEDIATE EDUCATION U.P. BOARD OF HIGH Matric/ SCHOOL & JIC,K.B.PUR,SULTANPUR SCIENCE,MATH,ENGLISH 463 77 1/1 Secondary INTERMEDIATE EDUCATION U.P. BOARD OF HIGH Sr. Secondary/ SCHOOL & JIC,K.B.PUR,SULTANPUR PHYSICS,MATH,CHEMISTRY 356 71 1/1 Intermediate INTERMEDIATE EDUCATION Graduation Others Examination Passed Name of the Institution

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Others In case of grades, please mention equivalent % of marks and also enclose authenticated conversion formula 7. Family Income per annum (in Rs.) : 30000 Please enclose Income Certificate) 8. (i) Course in which studying: B.TECH (ii) Academic Session : 2013-2014 (iii) Duration : 4 Yrs. (iv) Year in which studying: IIIrd Year 9. Name and address of the institution where KANPUR INSTITUTE OF studying : TECHNOLOGY,KANPUR Address : A-1,ROOMA INDUSTRIAL AREA,KANPUR NAGAR U.P. 208001 District : KANPUR NAGAR State : UP Pin : 208001 10 Whether hosteller or a day scholar please specify: Day Scholar (If hosteller, please specify whether provided by the institution or own arrangement). (please enclose certificate) 11. Details of Scholarship/Stipend/financial NO assistance being received for the same course (if any). 12. Any other information applicant wishes to provide. NO I hereby declare that information provided above is true to the best of my knowledge and I am aware that providing wrong information will make me liable to legal action and recovery of scholarship amount. Date: Place: Enclosures: (i) Academic record attested copies of relevant certificates/mark sheets for the qualifying examination. Name & Signature of the applicant

(ii) Proof of annual income - Proof of income shall include last salary slip of parent/guardian, acknowledgement of income tax/income certificate from revenue official/gazetted officer/public representative e.g. MP, MLA, MLC, Panchayat officials etc.; (iii) Attested copy of Disability certificate; (iv) Course fee receipt if any, duly paid during the academic session; (v) Receipt/Invoice of eligible assistive devices duly countersigned by the authorized signatory of the institution;


Recommendation of the institution

Recommendation of the institution (only one application per student is to be recommended)

1. Certify that ASHUTOSH KUMAR SINGH is studying in course of B.TECH which is (please tick the relevant or specify) Diploma/Degree/PG level study/any other (please specify) studying in and is presently

(Tick whichever is applicable)

I Year 4 Yrs.

II Year

III Year

IV Year

The duration of the course is

2. The information furnished above by the student is in order and correct as per records of the Institution. 3. The family income as per record of the institutions is Rs. 30000 per annum. 4) Intuitional Bank Account Details a)Bank Name : b) Bank Branch Name : c) Bank Address : d) Account No. : e) IFSC Code: (Note: Please provide the Bank Details, so as course fee amount of scholarship shall be transferred in this Account ) 5. The student is receiving scholarship/financial aid/stipend from not receiving any scholarship/financial aid/stipend from any other source as per records of the Institute. 6. General conduct of the student is satisfactory/ unsatisfactory (please strike out whichever is not applicable) 7. It is certified that this institution is recognised by Central Govt. / State Govt. / AICTE / UGC/ RCI or affiliated to recognised university_______________________________. 8. Course Fee for this academic year Rs._______________________________. {Excluding Hostel charges, books / stationary charges and caution money (for hostel and library etc.) }

Date: Place:

Signature & Name of Head of Institution Registrar/Dean Seal of the Institution