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-2- ol/scHl2)/17 r3 HN/Lep

 GOVERNMENT OF KARNATAKA
eseeg i,qtc ta,l9qr6u
DEPARTMENT OF TECHNICAL EDUCATION. BANGALORE
dzrr.a.a/ Aqdr.cl e€A, aaedd ddd aaapr-dcddd d,aiJd cdr dd,ad 2017-t8d( Faoi
SCHOLARSHIP FOR CHILDREN OF HIV/LEPROSY AFFECTED PARENT'S FRESH APPLICATION FORM
FOR TEE YEAR 2017.1A

1. * i;rradonio{ d-drdld{ d))oa3d-Dn Egol,ooci ooddi!4 Eoddjaddcc)od l"dair$.

qjgF
edFci)Sr iCA,d dd6oo$ o$Ddde o-cjDd.6 d.Ddc)l eioabg OederolDdog. o$odde nd,oio
:joccig
"iod) dodl .odd, oedcrod A(J'oAQF dedJd$r di& dd!- drodcrDindjd.
Each sentence should be read carefully before the form is filled in. No changes will be permitted after
the application is submitted,Ifany entry is found incorrect, the scholarship willbe liable to be
can€elled forthwith.
2. C3. droad cd.i'lc$r &ondQrotD do;jorl iD-dgd.d Eorj(dd eoddroed dD9Jaodddc
! rra&ilc aa..

Filled application should be sent through the Principal ofthe College where the student studyinS.
3. ed,ord.6!.J cdrrle&4 6Dd]a OdQdA:Jd 6-Dcdd iiodd de&d (9d.ild&q dodrdne.n.bQ)Ae.
Incomplete applications or applications received after the prescribed date will no be considered.
gqlrQaos 6.q) :
1.
Name ofthe Candidate gcd.g/gc
flnCaDitalLetters) Smt./Sri.
z.
Father's Name Ee.bg/qe
flnCaDitalLetters) Smt./Sri.
3. dl,.ar.S / dJ{d.o(d Arcag 6aetd 6rd) :

Name ofthe HIV/LEPRoSY affected Darents

4. o$ad dnrild d)6-dndod ? 1, HIV
Mention disease ? 2, LEPROSY
5. "iig d&Fdgod ? d,o(i1- 6aO nd,.d-(& ?
From how manyYears? the disease has been affected?
6. gdroeo dg edgie.ohdooc ?
de)d63eo$
ndo ddrnro dgdd.q de* dr*dricd eQEoo/r.oFo e*rl$
eQ(ddddOod/de* dddsSco$ eQn!Oileod/o&ao6odd)
erQd"rd d.Jddood Ed.Dro dgid.i{ ddo$dddr. .
The medical certificate attached ?
The Medisal Certificate shall be issued bythe District
Leprosy officer/Govt. Hospital Suptd., Dist. Health olficer or
anv authorized Doctors,
7. ojJnd a6o.8Fi1 e96dro a-a6Qaca! a6e&Eoi lFE e,+-n
d, 8.od dr*d"oed6DJR d8q ddd ,o-Cr-O Do.G.uJ
Eidram dgdila eddo dr,f.o.a.ron ddJ ddd nodqiFdg
...sd.[,3 {idra& dgid$ edgnerDndoir ?
ls M.D.T certificale issued Lo Lhe students or parenls lor
undergoing Leprosy Treatment in present or in past yearc ?
orthe A.R.T certificate issued to the students or parents for
underqoinp HIV Treatment in present or in past years ?
03/scH(2)/17'13 Hrv/Lep
 =i n:3: ==:a: .-ia: I3-i::. a,i31;.::.
To which Category the candidate belongs to;
Caste & Income certificate should be enclosed
9. !5)s naFoo 5D:od i!!d)96"J tocjlCd did! -og)

Name and address ofthe Dresently pursuing College

10. 6C& ddaooq osd
iio(F Fdq d06Eod trto6,!6*o.
Mention the Course ofHe / She is srudying in
B.E/DIPLOMA
11. -lFori ,!od,96d Jda gddSo$ eodJti.l{.$d
e,lgielndo$ 6idri E+ ddFii noaoQ:,dog
nF..of.ncf.:, 6ortri 3Siouod eoidq dl6 dJ.ol).:r
eoddqo$${ erlSaC)ando$.
Wheather the student's degree marks cards & SSLC Mark
card or equivalent exam mark card or PUC mark card for the
first year is enclosed ?
12. i6nFo / (,$d003 @otJqd / sodooboo.f rod(ddg
-Df orl dJod,96ade.
Wheather the student is studying in Covernment or Aided
Dolwechnic/Ensineerins Colleses.
13. . e3d. aiJDod :
Date of Birth
. 50nd {c, dg r$e olq
Place of Birth, District and State
14. n6!dQFo$ d,oedd6 ieoEi / oo% iEoFo / $!rn drddd(
Whether the Parent's are Central or State Covernment or
Private Employee
15. eFq / aroo$o a{'Dx
Present or Permanent Address

16. sjerod d.oddD.d ioe{:- $6J68. i)d) dod/Eoob

:jod!F,
Contact Phone Number: Student & Father/Mother
.r.oc.A / $qd,oed a(Edo0ndv&eaddoRd)^ d)il I
$eeidd 6oodqd/lodbo$0orj. lodeddC -Dlo,l drDclrgdl * e,dFoog oeAd)d addfl$ ,g6do.b
€dJDr&!O$rei.
I swear that I am affected from the disease Hlv/Leprosy. My Son/Daughter and Applicant
Studying in the above named Polytechnic/Engineering College and I certified that the particulars made
above are correct.

X*, d.ocri &cag dJicgdd ,E

Place i Signature ofthe diseased parent

6daod : edE-6add lac

Date : Signature of the Applicant
-.4- 03/scHl2)/17-18 Hlv/L.o
Form - 9

Government of Karnataka
Finance Department
Department ofTreasu es
MANDATE FORM
Electronic Clearing Service (Credit Clearing)/ Real Time Gross Sedlement RTGSy National
Electronic Fund Transfer (NEFT) facility for receiving payments.

A. Details ofAccounts Holder (Student) : -

First Name

Name of Recipient (Students) SecondName:

Last Name

Institution / College

Course & l"', 2no, 3'o, & 4'n year

Recipient type (Category)

USN Number for 2m ,3'o, & 4' year

SSLC Reg. No. for l" year

AadhaarNumber

Voter lD

Complete Institution / College

Address 1

Address

Address 2 :

Pin Code :

Students
Mobile Number ofthe Recipient
Parents

E-mail ofthe Recipient

Fax Number (lnst./College/Offi ce)

 \

.d Bank Account Details oI the recipientr

Bank Name

Branch Name

Type of Bank Account (Please Select Savings ! / Current Account E

the type of BanI Account) *Minor E / Major fl
Account Number (as appea ng in the
cheque/Pass book)

9 digit M.I.C.R Code of Bank Brarrch

LF.S.C Code of the Bank

Documents Enclosed ! ehotocopy of the Cheque I-eaf issued by bank

T-l Photo copy of the A-mount Recent

Trarsaction(amount deposited/ with draw
-
E Zerox o( first page of pass book bearing
Accout Number
* The Student having a Minor Account in the bank cannot be accept€d to NEFI
Pfocess.
* Without Bank transaction cannot be accepted to NEFT process,

Date of Effect -
I
hereby declare that the particulars given above are correct and complete. If the
Eansaction is delayed or not effected at all ffi reasons of incomplete or incorrect information I
would not hold the Institution rcsponsible. I have read the option invitation letter and agree to
discharge responsibility expected of me as a participant under the Scheme.

Date: Signature of Student

Should be verilied By cose worker t

Date: Signature of Case worker

Date: dncipal Signature & Seal

Form - 9

Government of Karnataka
Finance Department
Department of Treasuries
MANDATE FORM
Electronic Clearing Service (Crcdit Clearing/ Real Time Gross Settlement RTGS)/ National
Electronic Fund Transfer (NEFT) facility for receiving payments.

A. Details of Accounts Holder (College hincipal) :

Name of the Recipient (Principal) First Name:

Second Name:

Last Name:

Institution/College

Office

Recipient tfp€ (Designation)

Aadhaar Number (Principal)

Votu ID (Principal)

PAN Number (Principal)

Provident Fund Number (Principal)

Complete lnstitution/College office Address Address 1

Address 1

Pin code

Mobile Number of the Recipient Self

Office & Residency

E-mail (e-mail oI the recipient)

Fax Number(of the Inst/College Office)

Remarks IF Any
 B, College Bank Account Details of the recipientr

Bank Name

Branch Name

T),?e of Bank Account (Please Select Savingsf Current Account !

the tJ,?e of Bark Account)

Account Numbel (as appeadng in the

cheque/Pass book)

9 digit MICR Code of Bank Branch

IFSC Code oI the Bank

Document Enclosed ! Photocopy of the Cheque LeaJ issued by bark

f-l lhoto copy of the Amount Re(ent
L-J Ttarsaction(amount deposited/with drdw
zerox of first page of pai, book bearing Account Number
!
* Without Bank ha.neaction can't be accepted to NEFI process,

Date of effectr
I hereby dedate that the particulars given above ate corect and complete. lf tlte
Transaction is detrayed or not effected at all for reasons of incomplete or incorect
information I would not hold the Institution responsible. I have read the option
invitation letter and agree to discharge responsibility expected of me as a participant
under Ale SclEme.

Date: Seal & Signatule of Principal