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ALL INDIA COUNCIL FOR TECHNICAL EDUCATION
(7n Floor, Chandralok Building, Janpath, New Delhi, I l0 001 )
Application Format
Scholarship for Girls under PRAGATI scheme
and
Scholarship for Differently abled students
F9R OEFTCE USF, ONLY:
SrNo of Aoolication
Year
Course
Whether lnstitute is Aooroved bv r\ICTE
ryn{)
Tg he filled bv the strldent:
Application for Girls
Scholarship (YesA{o)
Application for differently
abled scholarship
(YesAllo)
l.
photograph self
attest it with part of
the signature on the
photo and the
ication fornp
Full Name (ln Block Letter)
Sumame
First Name
Middle Name
Father's Name
Mother's Name
Student unique id
2,
Paste here a
passport size
Address for correspondence
Name
House Number
Mohalla/Street
City/Town/Villaee
District
State
Pin Code
Telephone/lVlobile
number. if anv
e-mail ID, if anv
3.
Parents Address
Name
House Number
Mohalla/Street
Citv/Town/Villase
District
State
Pin Code
Telephone/Mobile
if any
e-mail ID, if any
number,
4.
Permanent Address
Name
House Number
Mohalla / Street
City/Town/Villase
District
State
Pin Code
Tdephone/MoEle
number,
5.
if any
Date of Birth
D
6.
D
M M Y
Gender
Male
7.
Y
Other details
Relieion
Nationalitv
Female
Y
Y
Iel
Category(Open
/
SC/ST/OBC)
Whether
belonging to
Minority
comrnunity (Yes /
no)
Name of Minority
(if applicable)
Whether
differently abled
(PH) (Yes / No)
Category
of
disability
(if
aoolicable)
% Disability (if
applicable)
Disability
Certificate issuing
authority (if
aoolicable)
8.
Parent's Details (Mother / Father / Guardian (Tick appropriate)
Occuoation
Government
service (Yes A{o)
Semi Govemment
service (Yes A{o)
Private service
(Yes /Ir{o)
Business (Yes
A.{o)
Agriculture (Yes
A.{o)
Other (Please
soecifv)
Post / Designation
(if aoolicable)
Name of the office
with full address
(in which
employed, if
aoolicable)
9.
Details of educational qualifications from std. Xth onwards
.-f-
Sr.
Examination
No
Passed
University /
Board/
Institution /
Council of
Examination
Year of
Passing
Marks
obtained
Marks
out of
oZ
marks
obtained in
Board /
Division /
Class /
Grade
University
std xth
2
std
xllth
a
J
of course in which the student is admitted and scholarship is being sought
Name of Course
10. Details
)
a
J
4
5
6
7
I
Duration of Course
Part TimelFull Time
First Shift / Second Shift
Academic vear
Date of admission to first
year course in the current
academic vear
Class last attended (Xth /
XIIth / anv other )
l. Details of the Institution to which
the student is admitted for the current academic year
l-
1
Permanent id of the
2
Institute (PID)
Name of the Institute
J
Address of the Institute
4
District
5
State
6
Pin Code
Name of the Principal
Director / Head of the
7
Academic
Year
/
Institute
L2.Total Annual Tution Fee
Item
Sr
Annual tuition
No
Fee Paid (Rs)
Tuition Fee
Rupees (In words)
.i. Note: Please enter the "Tuition Fee" details and not the other fee like development
Library / Laboratory etc.
i
13. Details of Bank Account
of student (Joint account will not be allowed)
Name ofthe
Student
Name of Bank
Bank Account No
Bank IFSC Code
Bank Branch(full
address)
Branch code
Type ofBank
Account(Saving /
Current)
MICR code of
bank
Student PAN
number (if
available)
Enrollment- id
(AADF{AR) (if
available)
AADHAR- id
(rJrD) (if
available)
14. Annual
family Income of Parents of the student:- Rs. ...
..........
in
(Certificate of annual family income is to be given only in the prescribed format enclosed as
Annexure-llI along with the application).
15. Documents enclosed
with the application ( Attach following attested documents along with
the application)
Sr
Name of the document
No
2
a
J
4
Copies of mark sheet of standard Xth / XIIth / Others as
applicable and as filled up in Sr no. 09
Copy of annual family income certificate for the financial year
2013-14 in the prescribed format issued by Tahsildar or higher
officer
Copy of certificate issued by Competent authority in case of
differently abled candidate (PH candidate) (if applicable)
Copv of admission letter to Dinloma / Desree course
Attested
(Yes / No)
Attached
(YesA.,lo)
t{'n}"
'
9
Copy of Tuition Fee Receipt
Copy of Bank Pass Book showing
number, IFSC code and Photograph
Copy of stldent PAN card (if available)
Copy of AADF{AR card (if available)
Certificate issued by the Director/ Principal / Ueidrof tfie
l0
Institute (Annexure-I)
Declaration by Parents (Annexure-Il)
5
nam'@nt
6
7
8
16. Declaration by the student
l.
2.
3.
4.
5.
I hereby declare that the information given above is correct.
I have secured admission in first year Diploma / Degree program during academic
session 2Ol4-15 through centralized admission pro."r, .oriu.*O by state admission
counseling authority.
I am not availin$ any other Scholarship for this purpose from any other source.
I shall abide by the terms and conditions for sanction of the Scholarship.
I undertake, that if at any stage, it is found that the information given by me is false or if I
violate the terms and conditions of the Scholarship, the Scholarship sanctioned to me,
will be cancelled and the entire amount of Scholarship will be refunded by me or
recovered from me, apart from liability of penal action as warranted by law.
Signature of the Candidate:
Date:
Place:
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