Application for Scholarship [2018-19]

PLEASE TICK ONE ONLY

Merit-cum-means scholarship for MBBS / BDS / BPharm / BTech / BSc Nursing /

ATTACH A RECENT
BTech - lateral entry courses / Kundapur Mohan and Lata Bhandarkar
4.5 cms X 3.5 cms
AICTE tuition fee waiver for BTech courses (income below ` 6,00,000/- p.a.)
FULL-FACE,
25% scholarship on course fee for the students of SNM Polytechnic, Moodbidri / TMA Pai Polytechnic, Manipal
COLOUR
for BTech (lateral entry) course
PHOTOGRAPH HERE
10% scholarship on course fee for Konkani speaking students / Students studied in AGE colleges
25% scholarship on course fee for Konkani speaking students / Students studied in AGE colleges - admitted to
Allied Health / Nursing programs
Scholarship for Academy of General Education Students (SAGES)
Interest subsidy on education loan scholarship for eligible students
Manipal Foundation Scholarship for staff child / Spouse
50% tuition fee waiver for SOIS students
Dr TMA Pai Gold Medal Awardees of postgraduate programmes YEAR OF ADMISSION CATEGORY

FEE PAYABLE FOR THE CURRENT ACADEMIC YEAR

RUPEES / USD

NAME OF THE STUDENT Mr Ms Dr

ROLL # RANK # APPLICATION #

COURSE

INSTITUTION CAMPUS MANIPAL MANGALORE BANGALORE

DATE OF BIRTH MARITAL STATUS SINGLE MARRIED

DD / MMM / YYYY

RELIGION CASTE MOTHER TONGUE

NAME OF THE FATHER / MOTHER/GUARDIAN/SPOUSE

PROFESSION OF THE FATHER / MOTHER/GUARDIAN

RELATIONSHIP OF THE STUDENT WITH THE GUARDIAN

ANNUAL INCOME OF THE PARENT/GUARDIAN

PERMANENT RESIDENCE ADDRESS

ADDRESS FOR COMMUNICATION

TELEPHONE (with area code)

HOME OFFICE / WORK

MOBILE
PARENT STUDENT

EMAIL (in block letters)

PARENT STUDENT

Manipal Academy of Higher Education, Madhav Nagar, Manipal 576104, Karnataka APPLICATION FOR SCHOLARSHIP
 Have you availed Manipal Foundation Scholarship for any other child (In the case of scholarship on tuition fee for staff child/spouse) ? YES NO

If Yes, provide the details

BANK DETAILS (applicable only for interest on loan scholarship)

NAME OF THE BANK BRANCH

LOAN ACCOUNT NO. RATE OF INTEREST (P.A.)

ANNUAL INCOME OF THE PARENTS/GUARDIAN (attach family income proof/IT Returns) Rs.

LOAN AVAILED First Year Second Year Third Year Fourth Year Fifth Year

Rs. Rs. Rs. Rs. Rs.

PARENT BANK ACCOUNT DETAILS FOR AWARD OF SCHOLARSHIP

A/c holder NAME A/C NUMBER

NAME AND ADDRESS OF THE BANK IFSC Code

DECLARATION
I hereby declare that all the particulars stated in this application form are true to the best of my knowledge and belief. In the event of submission of
fraudulent, incorrect or untrue information or suppression or distortion of any fact, I understand that my admission/scholarship is liable for cancellation.

Signature of the applicant: Date:

Signature of parent/guardian: Date:

RECOMMENDATION from Head of the Institution (Where the student is studying)

Date: Signature of the Head of the Institution with seal

VERIFICATION from Head of the Institution (For the status of Staff)

In the case of staff child/spouse opting for scholarship on tuition /course fee
Employee is on the regular rolls/service Employee Name:
Employee has completed 3 years of service Employee ID: MAHE000

Remarks if any Date of joining:

Signature of the HR Department with seal Date: Signature of the Head of the Institution with seal

DOCUMENTS TO BE ENCLOSED
1 Merit-cum-means scholarship for MBBS, BDS, BTech, BPharm and
Dr TMA Pai Gold Medal awardees for PG programmes ....................................... > Income Tax Returns of parents*
2 Konkani scholarship ............................................................................................... > Certificate of proof for Konkani as mother tongue**
3 AGE scholarship .................................................................................................... > A proof of study certificate from Academy of General Education**
4 Scholarship to SOIS students................................................................................. > Mark sheet copy of previous exam of Manipal Academy of Higher Education
5 SAGES/ Merit-cum-means for BTech lateral .......................................................... > Income Tax Returns of parents*/ Income certificate from Tahshildar & study certificate
6 AICTE, Merit-cum-means for BSc Nursing, Kundapur Mohan & Lata Bhandarkar ... > Income Tax Returns of parents*/ Income certificate from Tahshildar**
7 Staff child/Spouse scholarship .............................................................................. > Income Tax Returns of parents*/ Income certificate from Tahshildar/Marriage certificate in the case of staff spouse
8 Interest subsidy on education loan scholarship ...................................................... > Income Tax Returns of parents*/ Income certificate from Tahshildar, loan a/c statement from the bank,
conduct certificate from Head of the Institution & certificate from the bank for interest payable for the
current financial year
> Mark sheet copy of previous examination of Manipal Academy of Higher Education for
applicable scholarships

* Non-working parents should produce a notarized affidavit that they are not employed.
** Along with first application only

NOTE: Incomplete applications will be disqualified Date: REGISTRAR

Manipal Academy of Higher Education, Madhav Nagar, Manipal 576104, Karnataka APPLICATION FOR SCHOLARSHIP PAGE 2