Prof.

Joseph Mundassery Scholarship Award 2020-21

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Registration ID 010035913318
1) Full Name ADHIL MUSTHAFA
2) Name of Father/Husband/Guardian MUSTHAFA AP
3) Occupation TEACHER
4) State/UT of domicile Kerala
5) Aadhhar Number 349557656311
6) Permanent Address
i) House No/Name ANAPPATTATHU
ii) Street/Locality KODALIPOYIL
iii) Name of City/Town/Village POTHUKAL
iv) Post Office BHOODANAM COLONY
v) District Malappuram
vi) State Kerala
vii)Pincode 679334
viii)Phone Number -
7) Address for Correspondence
i) House No/Name ANAPPATTATHU
ii) Street/Locality KODALIPOYIL
iii) Name of City/Town/Village POTHUKAL
iv) Post Office BHOODANAM COLONY
v) District Malappuram
vi) State Kerala
vii)Pincode 679334
8) Date of Birth 13/02/2002
9) Whether male or female Male
10) Nationality Indian
12) Details of educational qualifications from To be Verified by the head of the Verified Signature
matriculation/SSLC/SSC onwards Institution
13) Details of course based on which scholarship is being sought:
i) Examination Passed Physics, Chemistry, Biology,Mathematics
ii) Year of Passing 2019-20
iii) Is full A+ Yes(Full A+)
14) Details of Last Studied Course and Institutions
ii) Name of the Course HSC,Physics, Chemistry, Biology,Mathematics
iii) Name of the Institution CATHOLICATE HSS
15) Annual Income of parent/guardian of the student 708480
16) Details of Bank Account
i) Account Number 40158101089767
ii)Name of the Bank KERALA GRAMIN BANK
iv)Branch Code and Address 158,NettikkulamBazarP.O.UppadaMalappuramDT Pin-679354

IT Services:National Informatics Center(NIC),Kerala Page 1/2 Printed On: 10/11/2020 11:22

 Prof.Joseph Mundassery Scholarship Award 2020-21

Registration ID 010035913318
Full Name ADHIL MUSTHAFA
17) Documents enclosed with the application
(i) One copy of passport size photograph with signature pasted on the registration form.
(ii) Attested certificates of educational qualifications from matriculation onwards.
(iii) Income Certificate.
(iv) Minority community declaration/Community certificate.
(v) Proof of permanent residence/Nativity Certificate.
(vi) Attested copy of first page of bank pass book in the name of the student. Showing the Account
Number, Name, Code and Address of the branch.
(vii) Accommodation certificate in case of Hostlers.
(viii) Copy of Adhaar/Enrollment document.
18) Declaration
i) I hereby declare that the information furnished above is correct to the best of my knowledge and belief.
(ii) I am not availing any other scholarship for this purpose from any other sources.
(iii) I shall abide by the terms and conditions for sanctioning of the scholarship.
(iv) I understand that if at any stage, it is found to the satisfaction of the sanctioning authority that the information given
by me is false or I have violated the terms and conditions of the scholarship, the scholarship sanctioned to me, may be
cancelled and the entire amount of scholarship will be refunded by me, apart from liability for such penal actions
warranted by the law.

Place:
Date: Signature of Candidate
19) Remarks by Verifying Officer
Verified online the details given by the candidate with supporting documents and found
Correct/ Incorrect (Specify)

Place: Signature of Verifying Officer

Date: name:
Designation:
20) Certificate by the Head of the Institution

It is certified that the information filled in the above mentioned columns by shri/smt/kumari....ADHIL MUSTHAFA.........
S/O D/O W/o Shri..........MUSTHAFA AP........... who is admitted for .....Physics, Chemistry, Biology,Mathematics
.....Course in ..........CATHOLICATE HSS.............college is correct.

Place: Signature of head of the institution/college with official Seal

Date:

IT Services:National Informatics Center(NIC),Kerala Page 2/2 Printed On: 10/11/2020 11:22