Document 327635

APPLICATION form
Affix a self
attested
passport size
photograph
Personal Information
Candidate’s Name
Father’s/Guardian’s Name Mother’s Name
Telephone No
Mobile No. (Parents mobile no. can be provided):
Email:
Domicile State/UT (State/UT which the student belongs to): Date of Birth (DD/MM/YYYY)
Nationality
Annual Family Income (Rs.) Person with Disability (PwD)? Visual Impairment Category: No Spastic Locomotor Disability General Dislexic ST Hearing Impairement Autistic
Address for correspondence
City/Town/Village & PO District
Phone
Permanent address :
City/Town/Village & PO State
Mobile
SC Pincode
OBC
District
State
Pincode
Phone
Mobile
Annual Family Income (Rs.)
Details of educational qualifications:
Name of the School Studying in
Board School Affiliated with
School Address
City/Town/Village & PO State
Pincode
School Telephone No.(Including STD code)
School Email-ID
Principal’s Name
Presently Studying in:
EXAMINATION
PASSED
Principal’s Mobile
Class XI
Class XII
Board
YEAR OF PASS
Class X
OVERALL CGPA/
PERCENTAGE
SUBJECT GP/
PERCENTAGE
Given in CGPA or
Percentage?
CGPA
Percentage
Class XI
(For class XII
students only)
Maths:
Science:
Physics :
Chemistry :
Maths:
Details of Other Examinations /Test Cleared
NTSE
Maths Olympiad Science Olympiad
KVPY
NSEJS NBHM Other
Details of Bank Account of Student
Name of the Bank
Branch address
Bank Account No.
IFSC/RTGS/NEFT Code (11 Digit Alphanumeric Code of the Bank)
Preference of city in which you want to attend the contact classes (choose from the list of cities given in the brochure)
1
2
3
Annual Income of parent/guardian of the student : Rs
(Specimen form of declaration of annual income is given at Annexure which is to be signed by the parent/guardian of
the student and enclosed alongwith the application. In case parent/guardian are employed, income certificate from the
employer may also be enclosed)
Documents enclosed with the application
(i) One copy of passport size photograph with signature.
(ii) Self attested certificates of educational qualification as filled up in para 09.
(iii) Income declaration - affidavit on non - judicial stamp paper and income certificate from the employer.
Declaration :
(i) I hereby declare that the information given above is correct.
(ii) I am not availing any other scholarship for this purpose from any other sources.
(iii) I shall abide by the terms and conditions for sanction of the merit-cum means based scholarship.
(iv) I undertake, that if at any stage, it is found to the satisfaction of the sanctioning authority that the information given
by me is false or if I violate the terms and conditions of the scholarship, the scholarship sanctioned to me, may be
cancelled and the entire amount of scholarship will be refunded by me or recovered from me, apart from liability for
such penal action as warranted by law.
Date :
Place :
Signature of the candidate
FOR OFFICIAL USE ONLY
Sl No. of Application
Year
Class
Gen / SC/ST/OBC
Annexure
DECLARATION OF FAMILY INCOME
I...............................................................................................(Father/Mother/Guardian) of ........................................
............................................(Name of Student) who is studying in ..............................................................................
...........hereby declare that my annual income from all sources is Rs./.........................................in word......................
......................................................................................................if at any stage, it is found that the information given
by me is false/not true, all benefits given to the student under the scheme of “UDAAN” could be with drawn and legal
action as deemed fit may be taken against me or my ward.
Signature
Date :
(Father/Mother/Guardian) Residential Address
Undertaking by Parent
I ......................................................................(Father/Mother/Guardian) of .....................................................have
understood the terms and conditions of the Udaan program and agree to abide by them. I promise to support my
daughter for the duration of the program and will ensure that my daughter sincerely participates in the program.
I also understand that as part of this program my daughter will be required to attend contact classes on the weekend at
a centre appointed to her. I will support her in attending these classes.
I agree to ensure the safety of the tablet and study material given to her and promise to return the same in the event she
discontinues from the program.
Date:
Signature:
Name:
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