Scribd
Upload
46 views

Part - A: Fresh Application Form

The document is a fresh application form for a Post Matric Scholarship for Scheduled Tribe students in Manipur, India. It contains instructions for applicants to fill out sections on personal details, family details, educational details, declaration of accuracy, and required documents. It also contains instructions for educational institutions to fill out verification of enrollment. Key requirements include submitting income certificates, caste certificates, and opening a bank account in the applicant's name only to receive scholarship funds electronically. The last date to submit applications is November 30th and incomplete or late applications may be rejected.

Uploaded by

rakeshrakesh1
Copyright
© Attribution Non-Commercial (BY-NC)
Available Formats
Download as PDF, TXT or read online on Scribd
46 views

Part - A: Fresh Application Form

The document is a fresh application form for a Post Matric Scholarship for Scheduled Tribe students in Manipur, India. It contains instructions for applicants to fill out sections on personal details, family details, educational details, declaration of accuracy, and required documents. It also contains instructions for educational institutions to fill out verification of enrollment. Key requirements include submitting income certificates, caste certificates, and opening a bank account in the applicant's name only to receive scholarship funds electronically. The last date to submit applications is November 30th and incomplete or late applications may be rejected.

Uploaded by

rakeshrakesh1
Copyright
© Attribution Non-Commercial (BY-NC)
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 3

n

sio
s
4
i
3
FRESH APPLICATION FORM
3 - 1 subm 2 0 1
1
0
,
Post
Matric
Scholarship to Scheduled Tribe students
2 of e r
b
e
(
Sponsored
by
the
Ministry of Tribal Affairs, Govt. of India )
m
t
da o v e
t
PART - A
s
N
La 0 t h
[
Part-A
is
to
be
filled
in
by
the applicant in his/her own handwriting ]
3

To

The Director,
Tribal Affairs & Hills ( Tribal Affairs Division ),
Government of Manipur, Imphal - 795 001.

Paper size - Legal

Recent
Passport size
Photograph
with applicants
signature thereon

Sir,
I wish to offer myself as an applicant for award of Post Matric Scholarship to ST students for the academic
session of 20 .....- 20....
and my particulars are given below : 1. (a) Full name [ in BLOCK LETTERS ] : ................................................................................................................................
(b) Date of birth (enclose Class-X Certificate ) : ........ /........ /...............(c) Name of Tribe : ...........................................
(d) Religion : ................................... (e) Nationality : ............................. (f) Mobile Phone No. .......................................
(g) Full permanent address : .........................................................village/town, .................................................Sub-Div.,
........................................................District, Manipur. (h) E-mail address :
2. (a) Fathers name
: ................................................................................................
(b) Occupation
: ................................................................................................
(c) Mothers name
: ................................................................................................
(d) Occupation
: ................................................................................................
(e) Total Annual Income [ b + d ] Rs......................
3. (a) Present course of study
:
(b) Duration of the course
:
(d) A Govt.nominee or private :
(e) University Regd.No. & year:
(f) Regular / Correspondence :
(g) Name of college/school/ins
with full postal address

..................................................................................................................
From 20..... to 20.....
= [ ..................years] (c) Class Roll No..............................
...........................................................................
...........................................................................
...........................................................................
................................................................................................................................
....................................Street.................................................................................
City/Town: .............................................................District...................................
Pin Code No.
STATE................................................

(h) Students Bank A/c No. ...................................................................... Banksname :...............................................


Name of Branch :
( Bank account should be in the name of the applicant. See instruction Sl.No.8 at overleaf )
(i) Hosteller / Day Scholar
: ...............................
(j) If Hosteller, specify
(i) Name of Hostel :....................................................................
(ii) Room No.
: .....................
4. Details of Board / Council / University examination(s) passed : ( See instructions Sl.No. 3 at overleaf )
Sl.No. Exam.passed Div.
Roll No.
Year School/College/University
Board/Council/University
(1)
(2)
(3)
DECLARATION OF THE APPLICANT
I declare and certify that (1) the above statement has been filled-up in my own handwriting and certify that they are
accurate and true (2) I have not applied/received any scholarship/stipend from any other source (3) I am not employed in any
Govt./semi-Govt. establishment (4) if any statement made by me is found wrong or misrepresented, I undertake to refund in full
the scholarship amount drawn by me (5) in the event of any dispute arising in the award of scholarship, I further give my
consent to abide by the instructions for filling up of this application Form and the decision of the awarding authority which
will be final and binding upon me.
Dated :
Place :
Full signature of the applicant
FOR USE OF THE AWARDING AUTHORITY ONLY
Code No.
HSLC Roll No.

Year

Division

Board

(1) Academic session :


(2) Class/Course
(3) 1st / 2nd / 3rd / 4th / Final year
(4) Period : from_____________to _____________
(5) Rate of Maintenance Allowance :
(i) Hosteller / Day Scholar = Rs.
x _____months = Rs.
ACCEPTED
(ii) Non -refundable fees
............................................. = Rs.
(iii) TOTAL [ (i) + (ii) ]
............................................
= Rs.
REJECTED
Reason(s) for rejection: (1)Incomplete entries (2) wrong entries (3) excess income ceiling (4) double apply
(5) absence of ...........................certificate (6) absence of applicants or head of institutions signature (7) doubtful
handwriting of the applicant (8) doubtful or old passport photograph
Signature of D.A.

Signature of Scheme Officer

To be printed on the back side of PART-A

PART - B
( To be filled in by the college/school/institution authority only )
1. Certified that the applicant is actually enrolled in this school/college/institution with effect from................................
and studying in................................class/course for the academic session of 20....... -20...... under admission number
............................................roll number...............................
2. The duration for completion of the whole course is from ......../......../20......... to ......../........./20.......... = (..........years )
3. This institution is affiliated to ...................................................................................University/Council/Board
( An attested Xeroxed copy of affiliation order/letter to be submitted ,if not submitted earlier)
4. If it is a Govt. institution specify name of the State
: .................................................................
5. If it is not a Govt.institution specify Recognition No. .....................................under Govt.of.........................................
( An attested Xeroxed copy of recognition order/letter to be submitted,if not submitted earlier )
6. Particulars of all non-refundable compulsory fees paid by the applicant for the yeaar 20 ....-20.....
( excluding Mess & Hostel fees ):(i) Tuition fee
Rs.
(ii) Examination fee
Rs.
(iii) Library fee
Rs.
(iv) Games & sport fee Rs.
(v) Medical fee
Rs.
(vi)
TOTAL Rs.
(Rupees.......................................................................................................

Date :
Place :

Signature of the institution head / authority

Name in BLOCK LETTERS


(
)
Designation with Seal
:
Fax No.
:
E-mail address
:
Website address
:
( Round Seal )
Telephone No(s). ( STD Code No. ____________ ) _______________________
Full Postal address of the :
institution with Pin Code No.
Note : (1) Stamped signature will not be accepted (2) Official seal of the head of institution, round seal of the institution,
Telephone No. and address Pin Code No. are compulsory (3) Full Postal address should be clearly indicated for correspondence (4) The application form will be rejected if found incomplete or filled in Part-B by the applicant . (5) The application
form will also be rejected if full address & particulars of the institution as given above are not clearly indicated

INSTRUCTIONS FOR FILLING UP OF THIS APPLICATION FORM


1) This application form is only for Fresh applicants [ viz (a) XI Class, TDC-I year, MA-Previous, I-MBBS etc. etc. OR
(b) XII Class, TDC-II/III year, MA-Final, II/III/IV-MBBS etc. who did not apply in the previous year(s) ]
2) Students having a study break should furnish an Affidavit / Certificate stating the reason of break in his/her academic
studies.
3) TO BE ENCLOSED / ATTACHED WITH THIS APPLICATION FORM :(a) An attested photostat copies of Certificates, Mark Sheets, Admit Cards of exam. passed as at Sl.No.4 of Part-A
(b) Income Certificate of father/mother/guardian/husband ending 31st March of the current year in original issued by the
competent authorities/executive magistrates
(c) Tribe Certificate of the applicant issued by the competent authorities/executive magistrates (attested photostat copy)
(d) Certificate in support of claim as Hosteller, issued by the warden of the hostel as at Sl.No.3 (j) of Part-A
(e) Break Certificate, if any ( as stated at Sl.No.2 above )
N.B.:- (i) Enclosed documents will not be returned.
(ii) The awarding authority may demand original documents for verification if required
(iii) The directorate will not be responsible for any loss of application form or documents.
4) Direct individual submission of this application form will not be accepted in case of students studying inside the State
5) The last date of receipt in this office is 30th Novermber, 2013. After the last date of submission no form shall be accepted.
6) It will be the responsibility of the concerned institution for not awarding scholarship if forwarded this Form after the
prescribed last date of submission.
7) AS PER THE INSTRUCTION OF THE GOVT., FROM THE YEAR 2012-13 ONWARDS PAYMENT WILL BE MADE
ELECTRONICALLY BY TRANSFERRING INTO THE RESPECTIVE BANK ACCOUNT OF THE APPLICANT.
SO EACH APPLICANT IS REQUIRED TO OPEN A BANK ACCOUNT IN HIS / HER OWN NAME AND
SHOULD COMPULSORILY FURNISH BANK ACCOUNT DETAILS GIVEN IN THE ANNEXURES - I AND II
( prescribed by the Govt.) ATTACHED HEREWITH THIS FORM.
8) The decision of the awarding authority is final.

kima renthlei \\ 23.07.13

ANNEXURE - I
AUTHORIZATION LETTER

I, ________________________________________________________would like to receive


the sums disbursed by the Tribal Affairs & Hills Department (Tribal Affairs Division), Manipur in my bank
account electronically as per details given below :- ( To be filled in neat and clear. The Tribal Affairs & Hills
Department,Manipur will not be responsible if the Scholarship amount is transfer to someone else Bank
account due to wrong or unclear filled in of Bank Account details).
1.

Name of the payee as in bank account

2.

Address

3.

Telephone Number with STD Code

Fax No.

5.

E-mail Address ( if any )

6.

Name of the Bank

7.

Name of Branch (full address )

8.

Bank Account No.

9.

Account Type

10.
11.

Mode of electronic transfer available in


bank branch ( RTGS / NEFT / ECS / CBS )
IFSC Code

12.

MICR Code

Account number has been verified by me


( Bank branch maintaining the Account )
Seal

Signature of the student

Name (in BLOCK LETTERS)

Course / Class

Name of the institutions with


full address

ANNEXURE - II
ACQUITTANCE / PRE-STAMPED RECEIPT (PSR) /
PRE-RECEIPT / ADVANCE RECEIPT
( Form of Acquittance for amount to be received through electronic transfer )
Received a sum of Rs.

( Rupees...................................................................

...................................................................................................................................................

) only

electronically from (DDO)................................................................................................................ on account


of the above amount sanctioned by theTribal Affairs & Hills Department, Manipur ( Office / Department ) vide
letter No................................................................................. dated .............................................

Place
Date

:
:

Signature
:
Name (
Course /Class :
Name of institution :
with full address

You might also like