Application Form for Scholarship (Not to be filled in by the student) APPLICATION NO: Ref No. Category………… Max.Limit ……No. of Scholarship Sanctioned so far ……… 1. Name Mr./ Miss..……………………………………………… 7. Amount of Scholarship Rs………………….. p.m. (Rupees……………………………………………. per month) D/o / S/o………………………………………………………………… 2. Present Course of Study …………………………………… 8. Period of Scholarship……………… years……..months 3. Duration of course ……………………. Years……………… 4. Whether Staying in Hostel…………Yes/No 5. Last exam. Passed ……………….. Marks : ……….…… % 1. 2. 3. 6. Family Income Rs………………… p.a. Sitaram Jindal Foundation Annexure II (to be filled in by the student very carefully) (To enclose documents mentioned overleaf) Note : Students can apply only once for the scholarship for particular course, if second application is made, scholarship will not be sanctioned and suitable legal action will be taken against the student for Misrepresentation of the facts. 1) Name in Full (CAPITAL LETTERS - as per marksheet) ……………………………………………… 2) Date of Birth : ……………………………… Nationality : ………………………………. 4) Addresses with Pin Code 3) Affix Passport Size Photograph attested by the Principal with Seal (a) Present address and Telephone No. Email-id : …………………………………………………………………….. …………………………………………………………………….. …………………………………………………………………….. (b) Permanent address and Telephone No. : …………………………………………………………………….. …………………………………………………………………….. …………………………………………………………………….. 5) Father’s/ Guardian’s name with phone number and email-id : …………………………………………………………………….. 6) Are you physically handicapped or Ward/ Widow of ExServiceman (State Clearly) : …………………………………………………………………….. 7) Occupation of Father/ Guardian & annual income of entire family from all sources. (If BPL Card holder, to enclose copy of BPL Card for verification) : …………………………………………………………………….. Rs.……………………………………………………….…. p.a. 8) Particulars of last examination passed Total marks & Percentage of marks obtained : …………………………………………………………………….. : …………………………..……% ……………………………… 9) Class/Trade/ Course in which studying at present Whether regular or part time or by correspondence : …………………………………………………………………….. ………………(Regular/ Part Time/Correspondence) 10) Name, address and e-mail id of School/ College/ Institute : ……………………………………………………………………. : ……………………………………………………………….…… 11) Duration of the Course : ………….. Years 12) Month & Year of Final Exam at the end of the Course : ………. Month 13) Total annual fees : Rs.………………………………………. p.a. 14) Whether staying in Hostel (If yes, what are the charges incurred per month) : Yes/No…………………………………………………………… : Rs.………………………………………. p.m. 15) Are you getting any stipend/ freeship/ scholarship from any other source. If so mention source and amount. : …………………………………………………………..Yes/No ……… Year : Rs.…………………………………………………………. p.m. 16) Have you applied previously to us for scholarship, whether it was sanctioned, if so, reference/file No. 17) Details of the bank account of the student Yes/ No : : : : Ref/ File No. ………….. Name of Bank & Branch …………………………………. Address ………………………………………………………… MICR Code …………… NEFT/IFSC Code …………….. A/c. No…………………………………………………………. I hereby certify that the information disclosed by me is true. I agree to abide by the Terms and Conditions of the Foundation prevailing from time to time. …………………………………………… (Signature of Father/ Guardian) ……………………………………… (Signature of the Student) Place : Date : It is hereby a) b) c) d) e) f) Principal/ Head’s Report certified that the particulars given by the student are correct as per the records of the School/ College/Institute. the student is/is not receiving financial assistance from any other source. the student is/is not physically handicapped/ disadvantaged. our school/ institute/ college is Govt./ Govt. Aided or Private …………………………….. (State clearly) our school/ institute/ college is affiliated to ………………………………………………. Board/ University/Council the student has not submitted any other application to Sitaram Jindal Foundation. Recommended that the student may be awarded the scholarship till ……………………………….. (month & year of final exam at the end of the course). Note : Principal/ Head should not forward more than 10 new applications (in addition to continuing scholarships) in a year. For BPL girl students - No Limit. (Signature of School/ College/ ITI Principal with seal) Important Instructions : Only self attested photocopies of certificates need be sent with the application form. 1. Family Income Limits : 2. 3. 4. 5. 6. 7. 8. a. b. c. For Cat 'A' scholarship - BPL Certificate. For those in employment - Rs.4.00 Lac per year. Certificate issued by the Employer. For all others - Rs.2.50 Lac per year. Income Certificate obtained from the competent authority of the area including Patwari, BDO, any Gazetted Officer, any Retired I A S, I P S or I R S Officer. Income Certificate format can be downloaded from our website. Downloadable Application form is available in our website www.sitaramjindalfoundation.org A student should apply for this scholarship only once in the duration of the course. Last date for receipt of application for the academic session 2014-15 is 31.12.2014. For the year 2015-16 onwards, the last date for receipt of applications will be 31st October of every year. Application received late will not be entertained. The student should not be getting any other scholarship from any other source. Only a maximum of 10 new scholarships (in addition to continuing scholarships) can be sanctioned for one college/ institution in a year. For BPL girl students - No Limit. Following certificates should also be submitted with the Application Form : i) For Physically Challanged - Certificate from a competent authority. ii) Marksheet of the last exam passed. iii) For hostelers, a certificate from the Warden in the prescribed form downloadable from our website. iv) For widows and wards of Ex-servicemen : a. PPO b. Ex-serviceman Widow I-Card c. Relationship Dependency Certificate Applications should be sent to the address given in the website. Please refer our website www.sitaramjindalfoundation.org for list of ITI trades, graduation & post graduation courses eligible and other conditions before filling up the form. Caution : Please ensure information and documents furnished are absolutely genuine and correct failing which action will be taken as we have stringent system of checking and verification by which some persons were caught & punished. (Attestation of the photograph by the Principal with Seal is must)