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APPLICATION FORM

NATIONAL OVERSEAS SCHOLARSHIPS/PASSAGE GRANT FOR
SC ETC. CANDIDATES, FOR THE SELECTION YEAR-2014-15,
UNDER THE SCHEME OF NATIONAL OVERSEAS SCHOLARSHIP
FOR SC ETC. CANDIDATES.
(To be filled in English or Hindi Language only in Block letters)
Passport size
Photograph to
be pasted here

S.No. Particulars
1.

Name (Shri/Smt./Km.)

Name

Surname

(According to Matriculation Certificate)
2.

Father's/ Husband’s Name:

3.

Date of Birth:

4.

Day

Month

Year

Years

Months

Days

Age

5.

Place of Birth ( with name of State/UT):

6.

Nationality:

7.

State/UT to which you belong:

8.

Religion:

9.

Caste: (Specify whether SC, Denotified Nomadic/Semi-Nomadic Tribes,
Landless Agricultural Labourer and Traditional Artisans)
(Attach self attested photocopy issued by the Competent Authority).

10.

Address (with Pin code No.)
a) Present address (Correspondence):b) Permanent address:
c) Nearest Railway Station
d) E-Mail ID, if any:

examinations Year of Subject Examin s ation passed (From % age of Class/ Marks Division obtained Details of published Research papers/books. please state their name. relationship with you and year of award. Particulars of academic/professional Matriculation or equivalent): Name of the Exam Passed Board/University Certificate/Degree /Institution Awarded 13. if any: Office/ Organisation Date of joining Date of Leaving Designation Nature of work 1 2 3 4 5 (b) 15. Monthly Salary including all allowances 6 Address Relationship Contact No.e) Phone Nos: Office _________________ 11. Other work experience. . Residence________________ Total Annual income from all sources for the year 2013-14: 12. Have any of your relatives been awarded this scholarship? If so. if any. if any: (Please attach a separate sheet for necessary action) 14. Next of kin in India to be notified in case of emergency: Name 16. (a) Employment particulars.

if any.17. If applied for any scholarships in the last 2 years.(Attach Offer Letter Also) Institution along with Course the accreditation details 20 Date of joining/Expected Conditions. . specify:- Institution along abroad Course with the accreditation details* Date of joining/Expected Conditions. of date of joining admission offer (with copies of relevant correspondence) *Provide document in support for applying in foreign Universities 21 Prospects in India after study abroad. 18.D. if any. Masters. Details of proposed study abroad (Details of proposed research in not more than 500 words should be attached) Specified of field Subject study (as mentioned in Sub-subject Research Topic scheme) 19./Ph. Degree/Programme for which scholarship is sought i. State the titles/results. of date of joining admission offer (with copies of relevant correspondence) If you have applied for admission and seeking assurance for scholarship. specify: . If you have already obtained admission in a duly accredited University/Institution abroad during 2014-15.e. 22.

Institutions where the course is to be provided. (Signature of candidate) Name of the candidate: ………………. details of arrangements made for meeting living and other expenses abroad.No Particulars 1 Details of foreign scholarship 2 Name of awarding authority 3 Whether it is a merit scholarship based on selection 4 6 If the scholarship is not adequate..FOR PASSAGE GRANT S. and details of course of study for which scholarship is awarded Date of joining the course 7 Duration of study abroad 8 Likely date of completion 9 Likely date of return to India 10 Amount of assistance sought from Govt. . and furnishing of false information by me will attract such action as detailed in the regulations of the Scheme. Dated: .. . Contact No………………………… Place:…………………. for economy class air passage to the country of study 5 Declaration I hereby declare that the above entries are true to the best of my knowledge and belief.

.. ......./Km.......was Rs..... per month..... (Applicant) is a citizen of India................../Km... shall however be treated as income................... ................... if the applicant is unemployed....... Tehsil............ Conveyance Allowance.......... or if supported by guardian (s)............. In case of salaried class....... Rs.......... Overtime Allowance....... The salary of the applicant (if employed) or of his parents/guardians...........*. month per District........... 2014 from all sources (i) of the employed applicant Shri/Smt............ (ii) of of village ......* ................... (Signature of competent authority)** Designation**/Address Date/Place Seal of Office NOTE: 1...... I further certify that Shri/Smt. (any scholarship or fellowship which the applicant may be receiving is not to be treated as a salary and may...... and rent-free accommodation shall not be included in determining the income...... So long as either of the parents is alive............./Km.... the total income of the living parents. including the income........... therefore be excluded). the total income of the guardian (s) has to be specified in case of unemployed candidate.......... his/her was father/Mother/Spouse/guardian* Shri/Smt.................. if any. Honoraria for undertaking other work........ from the landed property of other sources after deducting rebatable items as per income tax assessment has to be taken into account in declaring the income.. Special Pay and Bonus etc............ 2.........Income Certificate Form (to be attached in original with application) I certify to the best of my knowledge that the average monthly income in the preceding year ending 31st March...... Deputation Allowance.......

Service. (ii) The employer. In case the applicant is self-supporting or is himself/herself the head of the family.3. in case of parents /guardian(s)/applicant in private employment. and (iv) A gazetted officer of the Revenue of Sales Tax Department in the case of parents/guardians (s)/ applicant who are agriculturists or merchants. (iii) Competent gazetted officer of Government in case of parents/guardian (s)/applicant in private. ** The income certificate may be signed by one of the following as the case may be:(i) The Official Superior or head of the Department in cases where the parents/guardian(s)/applicant is in Govt. the total income of the applicant and of his/her spouse has to be specified. * Score out that which is not applicable. not in regular service. .

....Certificate for being Landless Agricultural Labourer This is to certify that Mr............................................. from all sources including the income of the other members of his family is Rs................(Name of Father/Husband or Head of Family) resident of ...................... It is also certified that the annual income of Shri............................... and he/she earns his/her livelihood by agricultural labour only...................................................................../Ms........has no agricultural land in his/her name or in the name of any of his/her family members..................................................only).......... Signature With seal of Revenue authority .................................................................................................. son/daughter/wife of ................. (Rupees ...............................................

...................................../Ms.........son/daughter/wife o f.............. (Rupees...................... (Name of Father/Husband or Head of Family) resident of .Certificate for being Traditional Artisan This is to certify that Mr.........................................................................is a Traditional Artisan and earns his/her livelihood by virtue of being a Traditional Artisan..../Ms................................. Signature (with seal of Revenue Authority) NOTE: This certificate should be issued by Revenue Officer not below the rank of Tehsildar.................. only)..................... from all sources including the income of the other members of his/her family is Rs........................................ ....................................... It is also certified that the annual income of Mr.....................