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FoundationforAcademicExcellenceandAccess(FAEA)

APPLICATIONFORMScholarship2015
Pleasefilluptherequiredinformation.
*Fieldsmarkedwithasteriskaremandatory.

P e rs ona lD e ta ils

1.*

FullNameasitappearsinyourSSLC/SSCcertificate

Mr.

1.b* Mother'sName
2.*

1.c*

CompletePermanentAddress
(withHomeState&City):

Father'sName
*

Home
State/U.T.

Select
SelectCity

* City/District

Ifothers,Specify

* PinCode
2.*

CurrentAddress(Addressfor
Communication)
ClickheretorepeatPermanent
Address

* State/U.T.

Select
SelectCity

* City/District

Ifothers,Specify

* PinCode
3.a* MobileNo.(10digitsonly)

+91

4.

FaxNo.withSTDCode

6.*

Gender

Select

7.*

DateofBirth(DD/MM/YYYY)

Day

Month

3.b

MobileNo.2/
TelephoneNo.
withSTDCode/

5.

EmailAddress

Year

Soc ia lBa c k ground

8.*

Category

Select

9.

IfSC/ST/OBC,
pleasespecify

10.*

DoyoubelongtoBelowPoverty
Line(BPL)Category?

Select

11.*

Doyouhave
Select
BPLCard?
Ifyes,givethe
BPLCardNo.

Select

Doyouhavea
physicalor
sensory
13.* disability?

12.*

DoyoubelongtoaReligious
Minority?

Select

Ifyes,please
specify
14.*

WhowasthefirstpersontocompleteMatriculation(uptoclass10)inyour
immediatefamily

15.a* Father'sEducationLevel

Chooseone

Select
15.b*

Mother's
Chooseone
EducationLevel

Educationlevels
Primary1stto5thor6th

Middle7thto8thor9th
Matriculation10thPass
SeniorSchool11thto12thPass
GraduationBA,BSc,orequivalent
PostGraduationMA,MSc,LLb,MBBSorequivalent/graduationintechnicalfield
DoctoralorhigherprofessionaldegreePhD,MPhil,LLM,MS,MDorequivalent

16.* Father'sOccupation

Father's
17.* Income(Rs.
perannum)

SelectFather'sIncome

18.* Mother'sOccupation

Mother's
19.* Income(Rs.
perannum)

SelectMother'sIncome

Educ a tiona lBa c k ground

20.*

22.*

Nameofthe
21.* Board(Class
XII/Diploma)

ClassXIIthSchoolName/Institute
NameDiploma

Whichtypeofschooldidyoustudy
in?

Chooseone

http://www.faeaindia.org/NewApps/Fill_application.asp

Nameofthe
City/Town/
Villageinwhich
yourClassXII Chooseone
School/Diploma
23.*
Insttitutewas

1/2

located
Ifother,please
specify

24.* ClassXIIMediumofinstruction:

Chooseone

Class
XII/Diploma
Wasita
25.*
residential
(boarding)
school

Chooseyear

27.*

Chooseyear

Class
29.* XII/Diploma
subject

Chooseone

Ac a de m ic Ba c k ground

26.* YearofpassingClassX
28.*

YearofpassingClassXII
Exam/Diploma

30.* ClassXII/Diplomapercentage
31.a* Proposedcourseofstudy

ClassX
percentage

%
Choosesubject

%
Choosecourse

ifothers,pleasespecify:

Areyoupresentlypursuingany
31.b Course
Select
*
(Graduation/Engineering/Diploma/PG
Etc)?
32.

Whydoyouwanttojointhis
course?
(notmorethan200words)

(optional)

Re fe re nc e D e ta ils

33.a Reference#1:Name

Gender

Reference#1Address

Choosegender

City/District
State/U.T.

Select

PinCode
ContactNo./MobileNo.#1

FaxNo.

33.b Reference#2:Name
Reference#2Address

ContactNo./
MobileNo.#2

EmailAddress

Gender

City/District

State/U.T.

PinCode

ContactNo./MobileNo.#1

Contact
No./Mobile
No.#2

FaxNo.

EmailAddress

Choosegender

Select

Declaration
IherebydeclarethatIhaveverifiedthedetailsindicatedaboveandIconfirmthatalltheinformationsubmitted
above is correct to the best of my knowledge. I will provide documentary evidence in support of all the above
information. If at any stage, if it is found that any of the above information is incorrect and/or is suppressed, the
managementofFAEAshallhavetherighttotakepenalactionasdeemedfit.

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