Space for

recent passport
size
photograph
HIGHER EDUCATION SUPPORT
PROGRAMME

Application form

1. Full name (IN BLOCK LETTERS)

(Mr. / Miss) ………………………………………………………………………………………

2. Gender:

3. Category: Gen( ) SC( ) ST( ) OBC( )

4. Contact details:-…………………………………………………………………………………….
i. Phone No: Mob:

ii. Email: …………………………………………………………………………………………

5. V & C centre: .………………………………Prog :……………………………Class: …….............

6. Date of birth: ……../………/…………… . Place of origin………………………..

7. Details of Parents / Guardian

Name of Father: …………………………………. Name of Mother: ………………………..
Relation (G): ………………………………………..
Occupation: ……………………………………… Occupation: ………………………………………
Income: ……………………………………. Income: …………………………………………..
Educational level: ………………………….. Educational Level: …………………………………

Family background:-
Number of Family Members: ……………………………………….
Family Income: ………………………………………………

6. Any other significant information (if you want to add) : ……………………………………………..

…………………………………………………………………………………………………………….

7. PREVIOUS EDUCATIONAL QUALIFICATIONS (Fill in all columns)*:

Class/Standard Board/ Name of School/ Year of Percentage

University College Passing
12th or HSC with Stream

10th or SSC

8. Give details, if any

(a) Proficiency acquired in games, sports & athletics and
(b) Part taken in other extra-curricular or social activities
1
9. Which are the subjects of Class 11th that you think you are good at or you enjoy them the most. This can be
more than one. Please also give reason [ आपक म म अलग अलग वषय आप पढ़ते ह उसम से कौनसे वषय म आप
यादा अ छा कर सकते है या फर कौनसे वषय म आपको यादा च ह. कारण के साथ बताए. एक से अ धक भी हो सकते ह.]

10. In which subjects do you think you may face challenges and why? [ कौनसे वषय म आपको द कत हो सकती ह और
यूँ]

11. In subjects where you face challenges, what different things will you do to overcome those challenges? [ िजन
वषय म आपको द कत ह उसके लए आपको या या करना होगा?]

12. What are your career goals –

a. What type of job / business / profession do you think would suit you the best / you will enjoy the most?
Please give reason. [आप अपने आपको कस कार क जॉब / बजनेस म दे खते हो िजसमे आप अ छा भी कर पाओ
और आपक च भी हो. कारण के साथ बताए]

b. For the choice of job / profession – what studies do you think you will need to do. Please do proper
search of course names and put it here. [िजस कार का काम आप आगे करना चाहते ह उसके लए कौनसी पढ़ाई
आपको 12th के बाद करनी होगी. सच करके कोस के नाम लखे]

2
 c. For getting admission in the choice of course after class 12 what type of entrance exam will you need to
appear for? [12th के बाद आपक चोइस क पढ़ाई के लए आपको कौनसी एं स ए जाम दे नी पड़ेगी?]

d. What will be the syllabus for the entrance exam? [एं ं स ए जाम का सलेबस या होगा]

e. What preparations would you do in Class 11 & 12 for your entrance exams? How? [11th & 12th म आप
एं ं स ए जाम के लए या तैयार करगे? कैसे?

Option 1 – Course Name: ___________________________________________________________________________

S.no Univ / College Name EntranceTest Form

Date / Merit filled –
Based Y/N
1

Why have you chosen this particular course/ Institute?

Option 2 – Course Name: ___________________________________________________________________________

S.no Univ / College Name EntranceTest Form

Date / Merit filled –
Based Y/N
1

3
 Why have you chosen this particular course/ Institute?

Option 3 – Course Name: ___________________________________________________________________________

S.no Univ / College Name EntranceTest Form

Date / Merit filled –
Based Y/N
1

Why have you chosen this particular course/ Institute?

13. After your class 12, you want to just study or you think you will need to work along side? What type of work?
Why? [12th के बाद आप सफ पढ़ाई करना चाहते ह या आपको लगता ह क साथ साथ आपको कोई काम भी करना होगा? कैसा
काम? यँू?]

14. Apart from studies, what type of personality changes / further exposure do you think you need to be prepared
for? [पढ़ाई के उपरा त 12th म और या या आपको करना होगा – पसना लट के लए, ए सपोजर के लए?]

15. What is your parent’s vision for your career / studies / profession etc. Whatever you know today or you think –
please write in detail. [आपके पेर स क आपे क रयर और आपक 12th के बाद क पढ़ाई / काम वगरह को लेके या सोच ह?
जो भी आज आपको पता ह और लगता ह वो व तार म लखे.]

4
16. Apart from Vidya & Child, whom do you consider as your guide / advisor etc. for your career and studies
planning? Please share as much details as possible. आपके क रयर और पढ़ाई के लए व या एंड चाइ ड के उपरा त
आप कनसे सलाह ले सकते ह या लेते ह? ल ज़ इसके बारे म व तार म बताए.

17. In Vidya & Child or in your relatives / siblings – names two – three children who you think have done well in
their career / studies and you get inspired from them. [ व या एंड चाइ ड म और आपके प रवार के दो- तन ऐसे ब च का
नाम बताए िजनक पढ़ाई / क रयर मवो अ छा कर रहे ह ऐसा आपको लगता ह और जो आपको कसी कार से भा वत करता ह]

18. Vocational training ( if applicable)

Name of Skill Training Duration Institute Date of Remark

Passing

19. Work Experience ( if applicable)

Name of company Job Profile Salary Time Remark

period

20. Have you applied for any Scholarship anywhere? If so, please give full details
(i) Year of Scholarship: ......................................................
(ii) Name of Course: ………………………………………….
(iii) Name of the Institute / University: .............................................

21. Any general remarks which you would like to offer

Date: …………………
Place: ………………..
Signature of Applicant