Application Number:

(For Office Use)

Government of Kerala
Backward Classes Development Department

Paste a recent
All details asked below must be clearly stated by the Applicant and no column must be left blank
Passport size
Full Name--------------------------------------------------------------------------------------------------------- photograph
here
Name of Father/Mother/Parent:--------------------------------------------------------------------------------

Age----------------------- Date of Birth--------------------------------- Marital Status--------------------------------------------

Religion/Caste----------------------------------------------------- Annual Family Income ----------------------------------------

(As per Income Certificate)

Permanent Address Present address

Telephone no: Telephone no:

(with STD code) (with STD code)
Mobile no:
E-mail address

DETAILS OF ACADEMIC CAREER: (From secondary school level)

Percentage
Name of Exam of mark
University /Board Subject Year Class Rank
School/College Passed (Must be
Accurate)

Any Special distinctions/Scholarships obtained -----------------------------------------------------------------------------------

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Post-Graduate and research work (if any)------------------------------------------------------------------------------------------

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Experience /Practical training (if any)-----------------------------------------------------------------------------------------------

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Employer’s name (if any)------------------------------------------------- Present salary: -----------------------Rs. Per Month

 Proposed course of study Years required

Sought at --------------------------------------------------------------------------------------------

Admission has been ------------------------------------------------------------------------------------------

Secured at------------------------------------------------------------------------------------------

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_____________________________________________________________________________________________

Total amount of scholarship required:---------------------------------------------------------------------------------------------

Other source of financial help:-------------------------------------------------------------------------------------------------------

(State source and amount)
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Name and address of two referees – under at least one of whom the Applicant has studied or worked:

1. ---------------------------------------------------------------------------------------------------------------------------------
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2. ---------------------------------------------------------------------------------------------------------------------------------
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The following documents must be enclosed with this Application: (Self attested copies)

1. Caste Certificate.
2. Income certificate.
3. A copy of Admission letter/ Offer Letter
4. A signed testimonial (letter of recommendation) from any one of the two referees mentioned above.
5. A short statement as to the general aptitude and interest, the type of vocation the candidate would like to
pursue and his/her ambitions and aspirations in life.
6. A copy of GRE/GMAT Score (if any).
7. Evidence of course and degree certificates along with Mark-sheets (Consolidated marklist with Percentage)
8. A copy of SSC & HSC mark sheet & School Leaving Certificate
9. Evidence of age.
10. Other documents if any.

If I am selected, I agree to abide by the terms and conditions of Government Order No. GO(Rt)11/2014/BCDD.
Dated:29.1.2014.

Date ------------------------------- ------------------------------------

(signature of Applicant)
Particulars regarding Parent/Guardian:

Name and Permanent address in full------------------------------------------------------------------------------------------------

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Occupation -------------------------------------------------------------------------------- Income per month-----------------------

Date -------------------------------------------------- -------------------------------------------------

(Signature of Parent/Guardian)