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INDIAN INSTITUTE OF TECHNOLOGY, KHARAGPUR

APPLICATION FORM FOR MERIT-CUM-MEANS SCHOLARSHIP & FREE STUDENTSHIP FOR RENEWAL
ONLY ( 2016-2017)
LAST DATE OF SUBMISSION: 29th July, 2016
N.B.: Before filling the form, read carefully the 'List of Documents to be Submitted '(Annexure-II) and the Notice for
MCM Schoalrship (Renewal) for 2016-2017 as shown in the ERP site (under General Message link) & also in
Institute Web site - > Quick Link -> For Students.

Roll No. :
Department :

13MI33002
MINING ENGINEERING

Name of Applicant :
Course :

ABHISHEK SINGH
MINING ENGINEERING SAFETY
ENGG. (M.TECH DUAL 5Y)

Category :
Hall :
Mobile :

GE
MEGHNAD SAHA HALL
7872834464

Room No. :
Email :

EAST2-E2-208
ABHISHEK2512ANKUR@GMAIL
.COM

MERIT STATUS :
(GPA(Credit based weighted average) of preceding two semesters i.e. GPA of Autumn & Spring Semester - 2015-2016
without any backlog):
(To be filled up by Academic Section ):
-----------------------------------

MEAN Status : ANNUAL INCOME OF FAMILY : (Income Documents to be enclosed as per guardians' Occupation as
stated in Annexure-I -'List of Documents to be submitted'
i) Fathers Gross Annual Income :
428663
ii) Mothers Gross Annual Income (if any)
0
iii) Annual Income from other source ,if any
0
(i.e. Investment in Bank/ Post Office/UTI/LIC/Share/Debenture/Landed
property/Income in the name of student etc. if any to be mentioned)
TOTAL of 6 (i) +(ii) +(iii) above
428663

FATHERs Occupation :

SERVICE

Mothers occupation
HOUSE WIFE
( Following documents to be enclosed as per mother‘s
occupational status with attested copies of Income Tax
documents, if applicable as stated in the Annexure-I List of
documents to be submitted.
Viz : if Service then Salary Certificate (Annex-II / If Business
etc. then Income Affidavit(Anenx-III) with Income Certificate
from concerned District Authority / If Pensioner, then
Pension Certificate ( Annex-IV) with Income & Nonemployment from concerned District Authority )

Father's Name :
MANOJ KUMAR SINGH
Name of Present Guardian : MANOJ KUMAR SINGH
(if parents are not alive and his
relationship with student.
Legal documents for such
guardian , to be enclosed)

Permanent Address

Mother's Name :
Relationship

KUSUM SINGH
FATHER

KATAIYA, Village/Town/City - KATAIYA,NEVADA, Police Station - LALGANJ, District PRATAPGARH, State - U.P., Country - , Pin - 230137