SCHEME OF SCHOLARSHIP FOR STUDENTS BELONGING

TO THE EWS CATEGORY

(Under Govt. of Uttar Pradesh)
FORMAT OF MAIN APPLICATION

FOR OFFICIAL USE ONLY

Sl. No. of application Year Course Whether approved

Affix a self attested

passport size
photograph

(To be filled up by applicant )

Part -I
1 A. FRESH OR RENEWAL ?

1. Full Name
( in block letters)

Surname

First
Name
Middle
Name

2. Father’s Name

3. Mother’s Name:

4 State/UT of domicile

5. Address for correspondence:

Name
House No.
Mohalla/Street
City/Town/Village
& P.O
District
State

Pin Code
Telephone no.
including mobile
number, if any.
e-mail ID, if any
6. Address of the parents.

Name
House No.
Mohalla/Street
City/Town/Village
& P.O
District
State

Pin Code
Telephone no.
including mobile
number, if any.
e-mail ID, if any

7. Permanent Address
Name
House No.

& P.O
District
State

Pin Code
Telephone no.
including mobile
number, if any.
e-mail ID, if any

8. Date of birth (please enclose certificate )

D D M M Y Y Y Y

9. Whether male or female:

Male Female

10. Nationality:

11. Religion:

12. Details of educational qualifications from matriculation /SSLC/SSC on wards (Please

enclose copies of certificates attested by a gazetted officer. )
Examination University/Board/Instit Main subjects Year of Percentage Division
passed ution/Council of passing marks /Class/
Examination Grade
13. Details of course for which scholarship is being sought:

(i) Name of class:

(ii) Duration of course:

(iii) Academic year:

(iv) Class/ course last attended /academic year.:

(v) Total Marks obtained and percentage in last examination:

14. Details of school/institution including residential ones:

(i) Name of the school / college/ institute where admitted:

(ii) Address of school / college/ Institute :

15. For renewal of scholarship:

Name of Year Marks obtained Full marks % of marks

examination
passed

16. Total Annual course fee: Rs……………….

(Break of course such as tuition fee, library fee, examination fee etc. other than
refundable deposits.)

Sl. Item Annual fee

No
1
2
3
4
5
6
Total

17. Day Scholar or Hosteller:

(i) Whether staying in the hostel run by the school/ college/institute

Yes NO

(ii)If not and staying as an outstation student as paying guest or in rented

accommodation in towns /cites which are not the places their parents resides,
then the complete postal address of the landlord of the paying guest/rented
accommodation may be given.
Name of landlord
Rent per month
Full postal
address

P I N
Telephone
/Mobile no. of
landlord.
18. Details of bank account of students.

(i) Name of the payee (as in the bank accounts)

(ii) Name of the Bank
(iii) Bank Brach (full address ) ___________________________
_____________________________
_____________________________

State _______________________________
District _______________________________
Pin ______________________________
(iv) Branch Code number __________________________________________
(v) Bank Account Number __________________________________________
(in words ________________________________________________)
(vi) Type of bank Account ______________________________________(Saving /current)
(vii) MI CR code of the Bank _____________________________________
(viii) Mode of Electronic transfer available in the Bank:-
ECA /RTGS/NEFT/CBS/code number (if any)

19. Annual Income of parents/guardian of the students : Rs____________

(Declaration of annual income is to be given in the prescribed format given below and is
to be signed by the parents/ guardian of the students and enclosed along with the application. In
case parents/guardian are employed, income certificate from the employer be enclosed.)

20. Document enclosed with the application.

(i) Self-attested passport size photograph with signature.

(ii) Attested copies of certificates of educational qualification as mentioned up in para12.
(iii) Income declaration –affidavit on non-judicial stamp paper worth Rs. 10/- for self-
employed parents/ guardian or income certificate from the employer for
employed parents/ guardian.
(iv) Proof of permanent residence on non-judicial paper worth Rs. 10/-
(v) Minority community declaration – affidavit on on-judicial stamp paper by the student
that he /she belongs to any one of the minority communities notified by Central
Government.

21 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.
I shall abide by the terms and conditions for sanction of the Post matric scholarship
(iii) I undertake, that if at any stage, it is found to the satisfaction of the sanctioning
authority in the concerned State Government /Union Territory Administration that
the information given by me is false or it 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 such
penal action as warranted by law.

Signature of the candidate

Date:
Place:
Part –II ( to be filled up by the Head of the School/ college/institution)

22. Detail of school/college/institute including residential ones:

(i) Name of the school/college/institute where admitted.

(ii) Address of school/college/institute.
(iii) Telephone no:
(iv) Fax No.:
(v) E-mail address:
(vi) If a private institute, is the school/ college/institute recognized ? If so. the name
of authority which has recognized it:
23. Verification /information to be furnished by the Head of school/college/institute.

(i) It is certified that the information filled in the above mentioned columns by Shri/Kumari
__________________s/o/do/Shri____________________________ who is admitted in
________________ course for the academic session ___________________ in
_________________ school /college/institute is correct.

(ii) He/she is a hosteller/day scholar of the school/ collge/institute.

or
He/she is staying as paying guest/in a rented accommodation at the address given at para
16 as per office records

(iii) He/she is a fresher admitted in the school /institute for academic year ___________
or
He/she has been promoted from _____________ to ____________in the academic year
______________

24. Details of bank account of schools/college/institute (For deposit of course fee):

(ix) Name of the payee (as in the bank accounts)

(x) Name of the Bank
(xi) Bank Brach (full address ) ___________________________
_____________________________
_____________________________

State _______________________________
District _______________________________
Pin ______________________________
(xii) Branch Code number __________________________________________
(xiii) Bank Account Number __________________________________________
(in words ________________________________________________)
(xiv) Type of bank Account ______________________________________(Saving /current)
(xv) MI CR code of the Bank _____________________________________
(xvi) Mode of Electronic transfer available in the Bank:-
ECA /RTGS/NEFT/CBS/code number (if any)

25. For renewal of scholarship.

It is certified that the above mentioned student has passed the ____________________
examination for ______________________(year) and has obtained ____________________% of
marks.

It is also certified that the student has not changed the course of study and /or the school/
college/institute of the study for which the scholarship was originally awarded/has changed the
course of study and /or school/college/ institute with prior approval of the State Government (please
strike out which is not applicable).

Signature of the Head of the school

College/institute with official seal

Date:
Place:
 DECLARATION OF PARENTS/GUARDIAN’S INCOME
(Specimen)

I ………………………………………………………(Fathers/Mothers/Guardian)
of ………………………………………..(Name of the Students who is studying in
…………………………………………..hereby declare that my annual income from all
sources is Rs./………………………………………………………
(in figures ……………………………………………………………………….
Rupees…………………………………………………………………. only (in words)

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 Post Matric scholarship for students belonging to minority communities”
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