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Applicant Information
Name: ___________________________________________________
Roll Number: _____________ Sex: ____ Date of Birth: _______________
Phone (Mobile): ______________ landline: ________________
Email id: __________________________________________________________________________
Engineering Stream: ______________________________ Semester: _________________

Marks (as applicable)

% Marks Mon-Year % Marks Mon-Year
1st Semester 4th Semester
2nd Semester 5th Semester
3rd Semester 6th Semester

Are you receiving any other scholarship, external aid, or financial aid?  Yes  No
(If yes, please specify type of award and amount)
__________________________________________________________________________________
__________________________________________________________________________________

Have you applied for educational loan from any bank?  Yes  No
(If yes, please specify amount and bank details)
__________________________________________________________________________________
__________________________________________________________________________________

Oath, Pledge and Declaration to be signed by the student and his/her parent / guardian
All of the information I have provided in this application and any additional material that I submit
related to the scholarship is complete, accurate, and true to the best of my knowledge and is subject to
verification by scholarship provider at its discretion. I am also aware that the Scholarship would be
discontinued if I fail in any of the subject.
For the support I am receiving from XSA, I pledge to support XSA by contributing to the education of
at least one student of MEC, once I am employed. I will keep XSA informed of my address and my
employment and occupational status.

I request you to renew the scholarship for the academic year 201_ - __

Student:_______________________________________ Date: _____/_____/_____

Check List: You must enclose all of the following with this application:
1. Copy of Mark lists (all semesters completed)

Application revised December 2012 1