2. Date of Birth (DD/MM/YY)
(as per X certificate)
3. Sex: Male OBC General
4. Category: SC
5. Physically Handicapped: Yes
5. Details of Father/Guardian/Husband (as the case may be) a. Name
b. Permanent Address Pin: c. Profession/ Designation with address Pin: 6. Details for Communication: a. Address for Correspondence Pin: b. Telephone with STD code c. Mobile No.
d. Email ID:
7. Whether father / guardian is a citizen of India: Yes No 8. Total annual income of both parents/guardian or husband’s income in case of married unemployed girl student (in Rupees). An income affidavit as per Annexure – III should be attached in support. 9. Particulars of School/Institution last attended Class XII (as per the school Transfer Certificate) a. Name of school / Institution
b. Date of entry (DD/MM/YY)
c. Date of leaving (DD/MM/YY)
d. Remarks, if any (if this space is not sufficient separate sheet may be attached.)
10. Details of Class XII Examination passed by the candidate: a. Name of the Examination passed: Higher Secondary Course Certificate Examination b. Register Number: c: Year of Passing: March 2012 State Board of School Examinations, Tamil Nadu, Chennai – 600 006
d. Name of the Board which conducted the examination passed by the candidate together with its headquarters. e. Total aggregate marks obtained in the examination: f. Percentage of marks obtained in aggregate 11. Is the candidate in receipt of any other scholarship from State Government or other institution or person (If yes, particulars should be given including the monthly rate and date from which the scholarship is drawn) 12. Particulars of Savings Bank Account of the Candidate: a. Account Number b. Name and Address of the Bank: C A N A R A B A N K
. Yes % No
c. Bank Branch Code Number:
d.IFSC Code: (11 digit bank code) 13. List of Enclosures sent with this data sheet (without enclosures application will not be considered) a. Income Affidavit (Annexure - III) Yes No b. Attested copy of Mark Sheet of HSC Certificate Exam 2012 Yes No c. Attested copy of SC/ST/OBC Certificate Yes No d. Joining Report (Annexure - V) Yes No 14. Certified that the statement made by me in this form is correct. I declare that in case I am selected for a scholarship. I shall devote my full time to the course of study, and that I shall not receive stipend/ scholarship from any other course.
Place: _______________ Date: ________________ ______________________ Signature of Candidate _______________________ Signature of Parent/Guardian
ANNEXURE GOVERNMENT OF INDIA MINISTRY OF HUMAN RESOURCE DEVELOPMENT DEPARTMENT OF HIGHER EDUCATION CENTRAL SECTOR SCHEME OF SCHOLARSHIP FOR COLLEGE AND UNIVERSITY STUDENTS STATEMENT OF PARTICULARS
Note: 1. Statement of Particulars, Income Affidavit and Joining report duly filled in should be handed over to the Head of the Institution, where the student has joined UG course. The Head of the Institution will forward it, to the Director of Collegiate Education, College Road, Chennai – 600 006 after attestation of Photo and Joining report. 2. Each item should be read carefully before the form is filled. No change will be permitted after it has been submitted. If any entry is found to be incorrect the scholarship, if awarded, is liable to be cancelled forthwith. 3. Incomplete statement or statement received after the prescribed date will not be considered. 4. Students may ensure that the completed Forms are forwarded by the Head of the Institution in time.
1. 2. 3. 4. 5.
Name of the Candidate (In block letters) (As per Class XII Certificate) Date of Birth (DD/MM/YY) (As per Class X Certificate) Sex : Male / Female Category: SC/ST/OBC/General (Pl. attach proof) Physically Handicapped (Pl....