K. C.

MAHINDRA EDUCATION TRUST

(Public Trust Act-Registration No. E 1245 - Bombay)

APPLICATION FORM FOR MAHINDRA ALL INDIA TALENT SCHOLARSHIP.

Application No. (Above entry to be left blank by the Applicant)

Here stick Passport size Photograph with your signature.

Read this Form carefully. Incomplete Application Form will NOT be considered. Applicants Name in full:_____________________________________________ Age _________ Date of Birth _______________________________ (as recorded in your School Certificate - Enclo. attested copy) (*) Address for Correspondence Pincode Telephone, if any : e-mail id, if any: ________________________

Category :

SC / ST / Others _________________________[Please specify]

Fathers Name in full : _______________________________________________________ Permanent address

Name of the State : Family Information :

Parents
Father Mother Any other Source of Income or scholarship(please specify amount and the no. of years)

Name

Level of Education

Employment / occupation

Income per month

Details of Applicants Educational record :

Name of School/ College

Name of Board/University

Examination Passed

Year

Percentage (*) of marks obtained

Proposed Course of Study (Give full details of your Diploma Course)

No. of years Required

Total College fees you have to pay per year

Do you live in a hostel?

Yes/No

If yes, how much does it cost you every month?________________________________

Admission sought at: Admission secured at: (Name and full address of the Institute) [Enclose copy of admission letter duly attested] * Course commences from Duration of the course Name and address of two referees - under at least one of whom the applicant has studied or worked. 1. [Date]

2. Enclosures: 1. 2. 3. 4. Testimonial from any one of the two referees mentioned above. A short statement as to your general aptitude and interest, the type of vocation you would like to pursue and your ambitions and aspirations in life. Attested copy of Certificate of Date of Birth as recorded in your School Certificate.* Attested copy of Mark Sheets and Certificates of examinations passed. Attested copy of Letter from Institution where admission has been secured. * Candidates who have not secured admission will not be called for the final interview. Therefore candidates should submit a copy of the admission letter as soon as they secure admission. I hereby declare that the entries in this form are true and if I am selected, I agree to abide by the terms and conditions of the K. C. Mahindra Education Trust, Mumbai. Date: Yours faithfully,

* *

[Name and Signature of Applicant]

Date:

[Name and Signature of Father/Guardian].

To the best of my knowledge, what is stated above is correct.

Date :

[Name and Signature of the Institution where you studied last/are studying)