Application no.:……………………………
CSIR-NORTH EAST INSTITUTE OF SCIENCE AND TECHNOOGY
JORHAT: ASSAM
APPLICATION FORM FOR AWARD OF CSIR-NEIST SCHOLARSHIP FOR DEGREE STUDENTS
(SCIENCE) 2016-17
1. Name in full (in capital letters):
2. Place and date of birth:
Affix a
Photograph of
3 x 3.5 cm
3. Married or unmarried:
4. Telephone/ Mobile No. :
5. (a) Father/ Guardian’s name in full :
(b) Nationality and state to which belongs :
Nationality:
State:
(c) Occupation:
(d) Address
:
Present:
Permanent:
6. Family Status
Name
:
Relationship Age
Occupation Monthly
income
Total
income
Remarks
7. Total monthly income from all sources
of parents/guardian (see Appendix C) :
8. Particulars of school/college/university, etc. where you studied (any break in the educational
career should be indicated in the remarks column).
Name of College/
Institution
Date of
Entering
Date of
Leaving
Year
Remarks
9. Particulars of all examination passed commencing with the Matriculation or equivalent
examination
Name of the
examination
Name of the Year
Board/
passing
Council
of Roll no.
10.(a) Name and address of the institution where admission
has been secured for the current academic year
Class
or Subject taken
Division with
% of marks
and Rank, if
any
:
(b) Date of admission
:
(c) Course and subjects taken
:
(d) No of years required for the completion of the course :
11. If the applicant is in receipt of any other scholarship or financial assistance from a State
Govt/University or any other institution or person, full particulars should be given including the
monthly rate and the date of award, etc.
12.List of documents attached :
(a)
(b)
(c)
(d)
(e)
(if this space is not sufficient, the additional sheet may be attached)
I hereby declare that the statements made by me in this application form are true to the
best of my knowledge and belief. I further agree to abide by the terms and conditions of the
award if I am selected for the loan scholarship applied for.
Place:
Date:
(Signature of the Applicant)
APPENDIX -A
16. (Certificate to candidate already enrolled in an institution)
Certified that Mr/Miss/Mrs……………………………………………………was admitted
into the College/Institution (Name)
…………………………………………………………………… as a regular full time
student in class on ………………… /20………
Place :
Signature of the Head of the Institution
Date :
(SEAL)
APPENDIX -B
INCOME AFFIDAVIT
I ………………………………. , Father/ Guardian of Mr/Miss/ Mrs.………………………….
a candidate under CSIR-NEIST Scholarship Scheme, declare that my total income including
income of my wife and of son/ward in the preceding year ending 31st March 2016 was
Rs………………….
……………………
Place :
Date :
Signature
(To be signed in presence of a Magistrate 1st Class/Notary Public who would also affix his
signature and seal)
(Signature)
Name & Designation …………………………
(SEAL)
APPENDIX -C
ELECTRONIC CLEARING SERVICE (ECS) DETAILS
Student Bank Account particulars
1. Applicant’s Name (Exactly as in Bank Account):
2. Bank Name:
3. Branch Address:
4. Bank Telephone No.:
5. Bank A/c Number:
6. MICR Code:
7. Bank A/c type (Saving/Current):
8. IFSC Code:
Dated:……………….
Signature of the Applicant ……………………………
APPENDIX - D
(This form is a specimen and a similar form which may be typed and it must be
submitted by each scholar in every semester on the announcement of examination
results through the principal/ Head of the institution last attended. This report must be
forwarded to CSIR-NEIST, Jorhat)
CSIR-NEIST Scholarship Scheme
Progress Report of the Scholar from ……………… to …………….
1. Name of the scholar (in Block Letters):
2. Name of the University/Institution/College:
3. Name of the examination passed in …………..to...………20…:
4. Date on which the scholar’s examination was over
(including particulars)
:
5. Class/Division secured (if only grades are allotted the
explanations of these grades as given in the marks
sheet must be attached)
:
6. Marks secured (subject wise)
:
7. Percentage of marks
:
8. Semester/Class to which promoted/admitted during 20….. to 20 ……:
9. Date of joining this /Semester/class (if the class has not started,
the likely date of start of the class) :
10. Total duration of the course in which studying or to which
admitted after passing the examination mentioned in column 3 :
11. Character and conduct of the scholar (General review)
:
12.Whether the scholar is in receipt of any
scholarship/stipend/ free studentship/ emolument etc.
from any source, if so, the nature and amount of such
scholarship
:
13. Specific recommendations of the Principal/Head of
the institution, etc. for the continuation of the
CSIR-NEIST scholarship
:
Signature:
(Full name of the Principal or Head of the institution)
Place : …………….
Date : ……………..
Designation:
(OFFICIAL SEAL)
INCOME AFFIDAVIT
Declaration of Income for the year (ending on 31 March of a year) for purposes of
scholarships granted under
CSIR-NEIST SCHOLARSHIP SCHEME.
I, Shri/Srimati/Kumari ………………………………………………….son/daughter/wife/
husband of ……………………………………………………………at present residing at
……………………………………..……………………………solemnly affirm and says
follows:1. That my son/daughter/dependent Shri/Kumari ………………………………………….,
who was selected in the CSIR-NEIST Scholarship, studying in
……………………………………………………… (here give the name of the institute)
2. That my annual income in the preceding year ending the
31st March 2016 is
Rs………………….as per detail furnished in the schedule hereunder written. I also
affirm that particulars of property held by me are as shown in the schedule and that I
have correctly indicated the amount on various taxes, cessess for the accuracy of the
facts and figures furnished.
3. That the statements made in the foregoing paragraphs are true to my knowledge. That
I further undertake that in the event of the particulars given in this declaration being
found false, I shall refund to the Director of CSIR-NEIST, double the amount of the
scholarship paid to the said scholar(s) and the award evaluation Committee’s decision
on whether the declaration of particulars is false shall be final and binding on me.
(Signature)
Name in full……………………………………
(To be signed in presence of Notary Public or a Magistrate
1 st/2 nd Class who would also affix his seal and signature)
(Signature)
Name & Designation…………………………………...
(SEAL)
SCHEDULE
I. EXTENT OF LAND HELD AND INCOME
*(a) Independently as owner
:
(i) Area:
(iv) Land revenue assessment:
(ii) Village:
(b) Jointly as owner
(i) Area:
(iv) Land revenue assessment:
:
(ii) Village:
iii) Survey No.:
(v) Annual Income: Rs.
(iii) Survey No.:
(v) Annual Income: Rs.
(c) Jointly as a tenant
(i) Area:
(iv) Land revenue assessment:
:
(ii) Village:
(iii) Survey No.:
(v) Annual Income: Rs.
II. PROPERTY HELD AND INCOME (House, shop building, House sites etc.)
(i)House No. :
(ii) Street/Road :
(iii)Village/town/City :
(iv) Area of site :
(v) Rent derived, if any :
(vi) House Tax paid :
(vii) Senitary cess or other :
(viii) Net annual income after deduction of item (vi & vii):
III.INCOME FROM SHOPS:
(i) Address of shop:
(iii)Sales tax, Income tax paid:
(ii) Nature of trade:
(iv) Annual Income:
IV. SALARIES DRAWN:
(i)Name of employer
:
(ii) Organization in which he is working & designation:
(iii)Address of office
:
(iv) Annual Basic pay for 2015 to 2016 without deduction of income tax:
(v) Other benefits like house rent allowance free, house and other perquisite:
V. OTHER SOURCE OF INCOME
(i)
Income from subsidiary industries
:
(ii) Part time occupation
:
(iii)
Any other income
:
VI. ANNUAL INCOME OF THE FAMILY FROM ANY SOURCE
:
VII. (i) TOTAL INCOME OF THE FAMILY FOR THE WHOLE YEAR 2015-16:
(ii) Average income for one month
:
Signature
(Parents/ guardian of the Scholar)
N.B.
(1) Total income of the family should include income of father and mother and the scholar and of other members who is
earning
(2) If father is dead, then mother’s income will be shown along with the income, if any, in the scholar’s own name from
shares, property etc. along with other family members
(3) Income for the purpose of means Test is defined as under:(a) In case of salaried class, the total pays plus income if any from other sources
(b) In case of income from sources liable to income-tax, income computed for purpose of assessment of income-tax
(c) In case of income not liable to income-tax such as income from agriculture, business etc., the net income that is
arrived at after deducting expenses incurred for earning that income.
EXPLANATION (I) : In case of persons drawing income from salary under clause (a) or clause (b) Dearness Pay,
allowances like dearness allowance, city compensatory allowance, House Rent allowance or value of rent free
accommodation, conveyance allowance and overtime allowances etc., shall be included in determining the income.
Deputation Allowance, Honoraria for undertaking other work, Special pay and bonus etc. shall also be treated as
income.
EXPLANATION (II) : For the purposes of determining the salary income in clause (a) & (b), from the basic salary will be
deducted all items which are allowable under the income Tax Act as deductions for computing taxable income.