SCHOLARSHIP APPLICATION FORM

Academic Year 2021

Application Date 2020, 5 October

College Name Padjadjaran University

Applicant Details
Applicant Name Reza Akbar Ramadhan

Mother’s Name Erni Setianingsih

Date of Birth 2002, 5 December Is Resident of Maharashtra YES / NO

Gender Male Orphan YES / NO Disabled -

Is Applicant Salaried YES / NO

Applicant’s Annual income Total Annual Income

Marital Status

Student Prequalifying Details

Last attended School/College/Institute. Senior High Shool Tanjungsari

Last Exam Passed STIC

Last Exam Passes Year 2020 Last Exam Marks 771.

Bank Name Branch Name

Account Number

Contact Details

Telephone Number Mobile Number

Email Address

Address for Correspondence

Pin-code Taluka District

Parent /Guardian Details

Name

Relation with applicant

Profession Annual Income

Hostel Details

Name of the Hostel

Hostel Admission Date Hostel Type

Is Mess Service Available YES / NO Rent per Month

Hostel Address

Pin-code Taluka District

Hostel Contact Details

Telephone Number Mobile Number

Email Address

Documents

Caste Certificate Number Issuing Office

Caste Validity Certificate Number Scrutiny Committee

Income Certificate Number Date of Issue

University Registration Number

DECLARATION
The information furnished by me is complete and correct. I bear the complete responsibility for all the
above information provided.

Applicant’s Signature

Parent’s Signature

Principal’s Signature