SCHOLARSHIP
APPLICATION FORM

Candidate Image (required)

Name of Candidate(required)

Sex: malefemale
DOB:

Father Name

Occupation

Type of Disability:

Visually ImpairedMentally RetardedAutisticHearing ImpairedLeprosy CuredLocomotor DisabilityMultiple Disabilities

Percentage of Disability:

Address Details:

Ph/ Mobile No.:

Address Details:

Email:

Annual Family Income:

Bank Details of Candidate:

Bank Details of Candidate:
A/C Holder’s Name
(As in Passbook):
:

Bank Name:

Branch Name: :

Bank Address :

Account No:

IFS Code No:
(Please enclose a self-attested copy of passbook/cancelled cheque)

Educational Details (Current):

Currently Studying in Class/Course :

Duration of Course (in yrs):

Academic Session:

Type of Institution:
Govt.Govt. Aided:Private:

Name of Institute:

Address of Institute:

Contact No of Institute:

Institute Email (if any):

Educational Details (Passed):

Examination
Passed
Name of the institution Name of the Board/University Percentage of
Marks /Grade
Obtained
Class VIII
Class 10th
Class 12th
Graduation
Others

Address of Institute:


DECLARATION

I ..................................declare that above information are true to the best of my
knowledge. If any information furnished by me turns out to be false subsequently, my scholarship may be
cancelled.

Signature of Father/Guardian Signature/Thumb Impression of Student

Date…………….. Date……………..
Place ………….. Place …………..


Verification by School/College/Institute:

I certify that ___________________________ is a regular/private student of our school/college/institute, currently studying

in class/course____________________________, his roll number is __________. He/She bears a good moral character.

Signature/Thumb Impression of Principal / Head of Dept.
Name: _______________________________
Designation: _______________________________
Contact No (if any): ___________________

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