Annexure A

Application Form for Internet Allowance

1. Name of Student:

2. Father's Name:

3. Mother's Name:

4. Class:

5. Course:

6. Date of Birth of student:

7. Mobile Number of Student:

8. Email Address of student:

9. Mobile Number of Parent:

10. Address of the student: Gali/street No....... Village/town............................, Tehsil................,

District.................... State.................

11. (A) Is student resident of Punjab (YES/NO)

(B) If yes proof of residence (attach copy of Proof)

(C) Adhaar Card No.:

12. Name of college :

13. Tehsil in which college is situated:

14. District in which college is situated:

15. Bank Details of Student:

a. Name of Bank:

b. Account Number:

c. IFS Code:

Declaration by Student:

I,......................., S/D of ....................... Studying in College, ......................., District....................... hereby do undertake

that the information as provided above is true and correct and that I am eligible for the Internet allowance. I shall be
responsible for all legal and financial consequences, in case information given above is found to be incorrect.

Date: Signatures of Student

Certificate by Principal

I have verified and satisfied myself that all the facts as given above by the student are correct as per the record. I
also certify that the student is regular student of my institution.