Account Code No.

_________________

Indian Institute Of Management, Nagpur
SPECIAL NEED-BASED SCHOLARSHIP FORM (SNBSF)
(To be filled in and signed by the applicant. Please keep a photocopy of the duly filled form and
attachments for your reference)

____________________________________________________________________________________________________

IIM NAGPUR IS PLANNING TO INITIATE SNBS. TO SET THE PARAMETERS / NORMS FOR ELLIGIBILITY FOR
THIS SCHOLARSHIP, THE SURVEY OF EXISTING BATCH HAS BEEN INITIATED. KINDLY FILL THE
ATTACHED FORM AND SUBMIT IT TO SAO OFFICE BY FEB 17, 2017.

KINDLY NOTE THAT THE FINAL DECLARATION OF THE SCHEME WILL BE INFORMED AFTER THE
APPROVAL OF COMPETENT AUTHORITIES.

___________________________________________________________________________________________________

Personal Information

1. Name of the student
(In block letters)

Last First Middle

PGP – I (Batch 2016-18) Roll No._________________

2. Phone No.: Land Line (________) _____________ Mobile __________________________
STD code

3. Present Address

4. Permanent Address

5. D.O.B

6. Marital Status: Single/Married

(a) If yes, what was the date of your marriage?

(b) If yes, please provide the following details:

What was the income of your spouse during 2016-17 in case
you were married for the whole or part of 2016-17? `

(Note: Income here means income from all sources prior to any deductions allowed by Income Tax
Act)

8. Were you working? If yes, since how long?

Also indicate the salary being drawn and the savings from your income

Salary: ` Savings: `
9. Indicate the amount of educational loan you intend to take for your studies (for 2 years) at IIMN
`____________

give: i) Designation of Father/Guardian : ________________________________________ Mother/Guardian : ________________________________________ ii) Address of employer : _____________________________________________________________________ ___________________________________________________________________________________________ iii) No. give details of previous job in items i). ii) and iii) above iv) Gross annual salary during 2016-17 Father/Guardian`____________________ Mother/Guardian `____________________ v) Income from other sources during 2016-17 Father/Guardian`____________________ Mother/Guardian `____________________ vi) Total income from all sources during 2016-17 Father/Guardian`____________________ Mother/Guardian `____________________ Total `_________________ . of years in service : ___________________________ (Note: If retired. Amount availed so far (for 1st year) ` _______________ Name of the Bank ___________________________________________ Branch______________________________ Loan Account No. _________________________ MICR Code ________________________IFS Code _____________ Rate of Interest per annum________ Terms related to Interest payment ___________________________________ Terms related to principal repayment _______________________________________________________________ Address of the bank______________________________________________________________________________ Parental Information: 1) Names of your Father/ Guardian : ________________________________________ Mother/Guardian : ________________________________________ 2) Age of your Father/ Guardian : ________________________________________ Mother/Guardian : ________________________________________ 3) Educational Qualifications Father/ Guardian : ________________________________________ Mother/Guardian : ________________________________________ 4) Occupations of your: Father/ Guardian : ________________________________________ Mother/Guardian : ________________________________________ 5) If any of the parents/guardians is in service.

No. Mother/Guardian i) Nature of business: Sole proprietor/Partner : __________________________________ ii) Indicate the name of the Company : ____________________________________________________ iii) Annual Income: YEAR------> 2016-17 `___________________ 7) TOTAL ANNUAL PARENTAL INCOME FOR THE YEAR 2016-17: (5vi + 6Aiii & Biii) `___________________ 8) Parents’ Principal Assets and Liabilities i) Life Insurance Policy Name of the insured Year in which Face Value of Annual Loan Present value policy taken the policy (`) Premium (`) outstanding. after if any (`) deducting loan outstanding (`) a) Father/Guardian b) Mother/Guardian c) Others ii) Immovable Properties House property (Indicate location and Present sale value Unpaid mortgage Difference (a-b) address) (a) (`) (b) (`) (`) Total Agricultural land. Father/Guardian i) Nature of business: Sole proprietor/Partner : __________________________________ ii) Indicate the name of the Company : ____________________________________________________ iii) Annual Income: YEAR------> 2016-17 `___________________ B. location. wet/dry. of acres (Indicate Present sale value Unpaid mortgage Difference (a-b) place. 6) If any/both of the parents/guardians is/are self-employed. give: A.) of land (a) (`) (b) (`) (`) Total Other real estate Present sale value Unpaid mortgage Difference (a-b) (`) of the property (a) (b) (`) (`) . etc.

vehicles. Market value of other investment . bonds. Total iii) Movable Properties i. Capital value of the share holdings (if doing business) ` ii. ` iii. with Income No. the student (PAN No. Name Age Relationship Monthly Occupation Income Tax Account No. etc. Sl. Provident Fund ` Total ` 9) List all the members of your family including the earning members with their monthly incomes and all dependents on the incomes. Savings (current account/fixed and bank deposits) ` iv.shares.) and Area Code a) b) c) d) e) f) Signed by Candidate: Date: .