APPLICATION FORM for Mobility Grants to the girl students studying P G Courses

(1" year and 2nd year) in State University or Autonomous College of Assam.

To,
The Registrar.. . ... .. . UniYersity(State).
(or)
The Principal....... . College(Autonomous).

[. Name ofcandidate (ln block letter)

2. Father's name

3. PAN No.

4. AADHAARNo.

5. Contact No & Email Id ofthe Applicant

6. Name oflnstitution presently studying

7. a) Name ofthe Course presently

studying ( PG)

b) Departrneot of the PG course

c) Year/Semester in which at presently

studYing

d) Date of admission in the course

8. Sex (mandatory) Female

9. Annual Income ofthe Parents (Income not to

exceed Rs. 5.00 Lakh per annum. Certificate
issued by the competent Authority is
mandatory)

10. Active Bank Account Details ofthe Applicant :(Readable Photocopy of l" page of Pass Book must be enclose)

Name of the A/c holder Name ofthe Bank Branch Name IFSC Code No Bank Account Number

I hereby apply for the State Govemment Mobility Grants for the year 2022 and declare that the information given in
this application is true and correct to the best of my knowledge and belief. In case any information given in this
application proves to be false or incorrect, I shall be responsible for the consequences and my candidature may be
rejected at any point of time.

Date:......... Full siqnature of the applicant.

\[. :- Hard copy of the Application Form along with all relevant documents is to be submitted to the
concerned Registrar or Principal only within l" September,2022 positiyely.