COMMON FORMAT OF APPLICATION
FOR POST MATRIC SCHOLARSHIPS
(CENTRALLY SPONSORED SCHOLARSHIP, STATE GOVT. SCHOLARSHIP
& HAJI MD. MOHSIN SCHOLARSHIP)
FOR OFFICE USE ONLY
SL NO.
YEAR
COURSE
APPROVED
YES
NO
REGN.
To
The Managing Director
West Bengal Minorities Development & Finance Corp.
Bhabani Bhavan, 2nd floor(west)
Alipore, Kolkata-700027
NO.
Affix a self attested passport size photograph I am submitting herewith my form for awarding me scholarship in any of the
above given three schemes as per my eligibility.
Yours sincerely,
………………………………………..
Signature of the candidate
Part – I [to be filled up by the applicant]
1. Full name:..……………………………………………………………………………………
(in block letter)
2. Father’s name………………………………………………………………………………..
3. Mother’s name……………………………………………………………………………….
4. State of domicile : ………………………………………………………………………….
5. Present 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
Photocopy of the form may be used.
1‐PMS‐CAF‐2008‐09 6. Permanent Address:
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. Date of birth (Please enclose certificate)
D
D
M
M
Y
Y
Y
8. Whether male or female:
9. Nationality:.………………………………………………………………………….……….
10. Religion:……………………………………………………………………………………...
11. Details of educational qualifications from matriculation/SSLC/SSC
onwards (Please enclose copies of certificates attested by a gazetted
officer/ head of the institution)
Year
of marks
Examination passed
Institute/Co Main
passing
University/Board/
uncil
of subjects
Percentage
Examination
2‐PMS‐CAF‐2008‐09 12. Details of course for which scholarship is being sought:
(i) Name of class/course: …………………………...…………………………………………
(ii) Duration of class/course: ………………………………………………………………….
(2yr, 3yr, 4yr, etc)
(iii) Academic year: ………………………………………………………………………………
(1st yr, 2nd yr, etc)
(iv) Class/course last attended/academic year: ………………………………………….
(v) Total Marks obtained :………………………………………………………………………
percentage in last examination:…………….…………………………………………….
13. Details of school/college/institute, including residential ones:
(i) Name of the school/college/institute where admitted:………………………………
……………………………………………………………………………………………………….
(ii) Address of school/college/institute….………………………………………………….
…………………………………..………………………………………………………………….
14. For renewal of scholarship:
Name
of
passed
examination Year
Marks
obtained
Full Marks
15. Total Annual course fee:
Rs……………..
(Break up of course fee such as tuition fee, library fee, examination fee etc. other
than refundable deposits payable to the school / college)
Sl.N
o.
1
2
3
4
5
6
Item
Annual fee
Admission & session charge, if any
Tuition fee payable to the institution
Examination fee
Library fee
Total
3‐PMS‐CAF‐2008‐09 16. Day Scholar or Hosteller:
(i) Whether staying in the hostel run by the school/college/institute
(ii) If not and staying as an outstation student as paying guest or in rented
accommodation in towns/cities which are not the places their parents
resides, then the complete postal address of the landlord of the paying
/rented accommodation may be given.
Name of landlord
Rent per Month
Full
address
Pin Code
postal
Telephone/Mobile
no. of landlord.
17. Details of bank account of student:
(i) Name of the payee (as in the bank accounts):………………………………………..
(ii) Name of the Bank: ………………………………………………………………………….
(iii) Bank Branch (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) …………………………………….
18. Annual Income of parents/guardian of the student: Rs._______
[Ensure that the income stated above tallies with the income in the affidavit /
income certificate. If differs form will be cancelled.)
(Specimen form of declaration of annual income is given at Appendix to this application form.
For Centrally Sponsored scholarship scheme the declaration in the form of an affidavit on a Non
Judicial stamp paper is to be submitted along with the application for self employed parents. In
case parents/guardian are employed, income certificate from the employer be enclosed.
For State Govt. stipend income certificate by A Group A Officer only.]
4‐PMS‐CAF‐2008‐09 19. Documents enclosed with the application
(i)
Self-attested passport size photograph with signature.
(ii)
Attested copies of certificates of educational qualifications as mentioned
up in para- 12.
(iii)
Income declaration – For Centrally Sponsored scholarship - affidavit on
non-judicial stamp paper for self-employed parents/guardian or income
certificate from the employer for employed parents/guardian.
For State Govt. Stipend, only the income certificate by a Group A Officer.
(iv)
Proof of permanent residence.
20. 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
source.
(iii)
I shall abide by the terms and conditions for sanction of the Post-matric
Scholarships.
(iv)
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 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 such penal action as warranted by
law.
Date:
Place:
Signature of the student
5‐PMS‐CAF‐2008‐09 Part–II [to be filled up by the Head of the school/college/institute]
21. Details of school/college/institute including residential ones:
(i) Name of the school/college/institute where admit: .…………………………………
…………………………………………………….………………………………………………….
(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: …………………………………………..…..
22. 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 / d/o 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/college/institute.
or
He/She is staying as paying guest/in a rented accommodation at the address
given at para 17 as per office records.
He/She is a fresher admitted in the school for academic year……………………..
or
He/She has been promoted from …………….. to ……………. in the academic year.
6‐PMS‐CAF‐2008‐09 23. Details of bank account of school/college/institute (For deposit of
course fee):
(i)
Name of the payee (as in the bank accounts: .…………………………………….
(ii)
Name of the Bank: ………………..……………………………………………………..
(iii)
Bank Branch (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): …………………………………...
Signature of Head of the
school/college/institute
With official seal
Date:
Place:
INCOME CERTIFICATE
(to be submitted if applied for State Govt. stipend / Haji Md. Mohsin Scholarship)
This is to certify that Sri/Smt. ------------------------------- father / gurardian of Sri
/ Smt. ----------- is a resident of ---------- He / She is known to me. His. Her
annual family income is Rs. ------------------- (Rupees ----------------------- only)
Signature of a Group A /
Gazetted Officer with Seal
7‐PMS‐CAF‐2008‐09 Appendix to the Application Form
(Specimen. To submitted if the candidate is applying for Centrally Sponsored Scholarship. Not required if
applying for State Govt. stipend or Haji Md. Mohsin Scholarship.)
DECLARATION OF PARENTS’/GUARDIAN’S INCOME IN THE FORM OF AFFIDAVIT
(on non judicial stamp of Rs. 10/ - )
I………………………………………………….……….……(Parents/Guardian)
of
………………………….…………………………(Name of Student) who is studying in
…………………………………….. hereby declare that my annual income from all
sources isRs………….(in figures) Rupees……………..…………………….…………only
(in words). That I belong to …………………………………… Minority Community.
If 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 “Post-matric scholarship for
students belonging to minority communities” could be withdrawn and legal
action as deemed fit, may be taken against me or my ward.
Date:
Signature
(Father/Mother/Guardian)
Residential Address
[Instruction for filling up the form]
Please ensure that the form is filled up correctly. Incomplete or incorrect forms are liable to be rejected.
1.
All columns should be filled up. Where information is not required, write N.A.
2.
Write correct percentage of marks.
3.
For course fee write only the fees which are paid to the school / college / institute. Do not include
any other fees. Give correct break up.
4.
Write correctly the MICR code of the Bank. It is advised that a Xerox copy of a cheque leaf is also
attached with the form.
5.
For column 17(viii) you are required to enquire with your bank if they have electronic fund transfer
facility i.e RTGS / NEFT / etc. If yes write their particulars carefully. If no, write N.A.
6A.
If you are applying for State Govt. Scholarship which is for Meritorious Students having annual
family income less than Rs. 80,000/- . You are required to submit the income certificate only signed
by a Group A Officer on the body of the form. Then affidavit is not required.
6B.
If you are applying for centrally Sponsored Stipend which is for economically weaker students, you
are required to submit the affidavit as per specimen given in the application form.
7.
Please ensure in column 23 that the particulars of the Bank A/c. of the school / college is correctly
filled up so that the fees can be electronically transferred.
8. Detail of your Bank A/c. particulars and school / college A/c. particulars are filled up correctly in the enclosed sheet and authenticated by the Bank Manager.
8‐PMS‐CAF‐2008‐09