VIDYA SCHOLARSHIP APPLICATION:

APPLICANT INFORMATION
Last Name First M.I. Date

Street Address Apartment/Unit #

City/Town State: ZIP Phone:

Email Address and Fax If Available:

Are you a citizen of India YES NO

ACADEMIC ACHIEVEMENTS:
Please enclose a copy of the score card of the final exam:

Course Being Pursued: Engineering, Medicine, Other:

Admission Secured (Please
YES NO Name of College:
Attached acceptance letter copy)
Estimated
Fees: Boarding: Lodging:
Annual Costs
Other Costs:

FINANCIAL SITUATION:
More details may be provided in the personal statement.

Father’s Name: Occupation: Monthly Income:

Address Of Employer:
Reference Name and
Phone Number:
Mother’s name: Occupation: Monthly Income

Address Of Employer:
Reference Name and
Phone Number

Brief Explanation Of
Need for Financial Help:

AGREEMENT AND SIGNATURE

I understand that if any of the above statements are proven false, the scholarship may be denied / cancelled. Also, if I do not complete
each semester or year successfully, my scholarships will be cancelled. I will submit the college score card to Vidya Scholarships at the end
of each semester/year. Upon completion of studies and start of income from regular job, I shall start refunding the money received (without
interest) so that other needy students can be helped.

Signature Date

11/9/2019 8:07:01 AM || Date Received: Application No: