POSTMATRIC SCHOLARSHIP FOR MINORITY STUDENTS

FRESH SCHOLARSHIP – 2010-11

Affix a
APPLICATION FORM Colour Photo
size3.5x4.5cms

Self Attest

STUDENT NAME
PARENT/GUARDIAN
NAME
PERMANENT
ADDRESS

PIN 6
Date Month Year
DATE OF BIRTH 1 GENDER (3) MALE FEMALE
RELIGION(3) CHRISTIAN MUSLIM SIKH BUDDHIST PARSI
Name of the Community
Permanent Community Certificate Number
B C C/M
(Dist Code) (Taluk Code) (VillageCode) (Certificate Number)
Community Certificate or Self Declaration Affidavit on Non-Judicial Stamp Paper of Rs.10/- by the Parent-Guardian of
student that he/she belongs to the Minority in Tamil Nadu notified by the Government of India)
ANNUAL INCOME OF THE PARENT/GUARDIAN Rs.
(Income Certificate from Designated Revenue Authority or Self Declaration Affidavit on Non-Judicial Stamp Paper of Rs.
10/- by the Parent/Guardian about annual Income to be given in the format enclosed
Student/Father/Mother’s Savings Account Number
Name of the Bank Branch Code
Record of Performance – 2009-10
Examination Passed Board/Institute Main &Ancillary Total % of
10/+2/ Year & University’s Subjects Marks Marks
Diploma/ Consolidated obtained
UG/PG Mark sheet No. out of
/
/
/
/
Scholarship sought for 2010-11
Name of the Class/Course studying Year I/II/III
Duration of Course Years Academic Year 2010 to
Details of Annual Course Fee:
Admission Fee Rs. Library Fee Rs.
Tuition Fee Rs. Other Non Refundable Fee Rs.
Exam Fee Rs. Total Course Fee Per annum Rs.

Date Signature of the Student

1
 DECLARATION

I, … . . . . . . . . . . . . . . . . . . . . . . . . . hereby declare that the informations given in my

application are correct and I am not availing any other scholarship for this purpose from
any other source. I shall abide by the terms and conditions for the sanction of Postmatric
Scholarship and undertake that if at any stage, it is found to the satisfaction of the
sanctioning authority of State Government of Tamil Nadu 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/recovered from me apart from such penal action as warranted by law.

Date : Signature of the student

Place:

Encl: Attested copies of certificates of 1) Educational qualifications 2) Community

Certificate from Revenue Department or Self Declaration of Affidavit on Non/Judicial
Stamp Paper of Rs.10/- by the Parent/Guardian 3)Latest Income Certificate: obtained
from Revenue authority not below the rank of Deputy Tahsildar ( or) Income
Declaration: For Self Employed Parents/Guardian: have to furnish Affidavit on
Non-judicial stamp paper of Rs.10/-. For Employed Parents/Guardians have to
furnish income certificate from the employer along-with affidavit on Non-Judicial Stamp
Paper of Rs.10/- 4)Proof of Permanent Residence 5) Savings Bank Account Details

Information to be furnished by the Head of School/College/Institute

It is certified that the information filled in the above mentioned application by
Shri/Kumari . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S/o (or) D/o . . . . . . . . . . . . . . . .
Who is admitted in .. . . . . . . . . . . . . .. . . . . . . .Course for the academic session . . . . . . . .
in our School/College/Institute is correct.

ii) He/She is a hosteler/day scholar of the School/College/Institute

iii) He/She has been promoted from to or passed all subjects in
the semester/non-semester examination(s) and secured 50% of marks in the
academic year . . . . . . . . .
iv) The scholarship will be disbursed after satisfying the yardstick of attendance
in the current year of the student.

Date: Signature of the Correspondent/Principal/Dean/Registrar

Place with Official Seal

* Strikeout whichever is not applicable.

2
 Specimen

SELF DECLARATION OF PARENT/GUARDIAN’S ABOUT INCOME

(on Non-Judicial Stamp Paper of Rs 10/-)

I, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . .. . . . . (Parent/Guardian)
of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (Name of the Student) who is
studying in . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . hereby declare that my
annual income from all sources is Rs.. . . . . . . . . . . .. . .(Rs. .. .. . . . . . . . . . . . . . . . . .. . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . .only).

I, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . declare that the above

information given by me is true to the best of my knowledge to avail the benefits given
to my son/daughter/ward and it is found that the information given by me is false, the
scholarship amount sanctioned could be withdrawn or recovered from me and legal
action as deemed fit, may be taken against me or my ward.

Signature of Parent/Guardian
Residential Address
Date:

--------------------------------------------------------------
Specimen

DECLARATION OF STUDENT’S COMMUNITY BY THE PARENT/GUARDIAN

(on Non-Judicial Stamp Paper of Rs 10/-)

I, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. (Parent/Guardian ) of .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .(Name of the Student) who is studying
in . . . . . . . . .Std. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (Name of theSchool) hereby
declare that the community of my son/daughter/ward is . . . . . . . . . . . . . . . . . . . . . . . . . . .
which is a minority community notifed by the Government of India.

If any stage, it is found that the information given by me is false/not true, all the benefits
given to my son/daughter/ward under the scheme of “Postmatric Scholarship” for
students belonging to the minority communities could be withdrawn and legal action as
deemed fit, may be taken against me or my ward.

Signature
Date
(Father/Mother/Guardian)
Residential Address