PRIYADARSHNI ACADEMY

Scholarship Application Form for ENGG. / B.ED./ MEDICINE / IT / ARCHITECTURE / MANAGEMENT 1. Name: Mr. / Miss.... (First Name) (Middle Name) (Surname) 2. Date & Place of Birth: ... 3. Address : . 4. Tel. No./ Mobile: Email Id : ...... 5. Educational Qualifications (See attached Sheet): 6. Extra Curricular Activities / Co-Curricular Activities (a) In School :

(b) In College : 7. 8. In Sports : ...

Any Recognition received in above categories (Please attach separate sheet, if required)

9. Name of Course Enrolled: ... Name of Institution: .... 10. Date of Enrollment: .. 11. Course Affiliated to University 12. Institution recognized by Govt.(State) 13. Declaration: I agree to abide by the decision of the jury and conditions laid down by the Education Committee of Priyadarshni Academy. My family's total income does not exceed Rs. Two Lakh per annum. I will voluntarily return the scholarship amount to Priyadarshni Academy if and when I am able to do so, so that the money can be used to provide scholarship to other needy and deserving students. Signature of the applicant Date: .

Forwarded through ... College/ University

Signature of the Head of the Institution (with Rubber Stamp)

Date:

Last Date for receiving completed Application Form is 31st December 2011.
Arcadia Building, Nariman Point, Mumbai 400 021. Tel.: 91 22 22873456 / 6630 7160 Telefax : 22875373 Email: pa@priyadarshniacademy.com

Name of Board / University Exam

STD. X

H.S.C.

Others F.Y.

Others S.Y.

Others T.Y.

Arcadia Building, Nariman Point, Mumbai 400 021. Tel.: 91 22 22873456 / 6630 7160 Telefax : 22875373 Email: pa@priyadarshniacademy.com

PRIYADARSHNI ACADEMY

Year & Month of Passing Exam

Name of School / College

Medium of Instruction Eng. / Hindi

Subjects offered

% marks obtained