MINORITY WELFARE POST MATRIC SCHOLARSHIP SYSTEMRenewalSTUDENT

Topics: Household income in the United States, Banking, Karnataka Pages: 12 (1237 words) Published: January 9, 2015
MINORITY WELFARE - POST MATRIC SCHOLARSHIP SYSTEM

Renewal

STUDENT APPLICATION

For official use only
Sl No of application

Year

Course

Student ID: T2012kapms070282

Whether approved

Affix a self
attested passport
size photograph

Roll No: 607

1.Student name

:

IMAN SHAHAB

2.Father's name/Husband's name

: Mohammed Ismail

3.Mother's name

: JAHARA

4.Mobile No
5.E-Mail ID

aimanshah18@gmail.com

6. Domicile State/UT (State/UT which the
student belongs to)

:

Karnataka

7. Address for correspondence:
House No. & Street Detail

D/o Mohammed Ismail, Bahar Manzil

City/Town/ Village & P.O.

60 feet road nehru Nagar

District

CHICKMAGALUR

State

Karnataka

Pincode

577101

8. Permanent address(please enclose residential certificate from concerned state government authority):
House No. & Street Detail D/o Mohamme dIsmail Bahar Manzil
City/Town/ Village & P.O. 60 feet road nehru Nagar
District

CHICKMAGALUR

State

Karnataka

Pincode

577101

9. Date of birth (Please enclose certificate) :

16-Aug-1992

10. Whether male or female

:

Female

11. Religion

:

Muslim

12. Nationality

Printed Date: 25-Oct-12

:

Indian

Page 1 of 7

13. Details of educational qualifications from matriculation/SSLC/SSC onwards (Please enclose certificates attested by a gazetted officer):
Examination University/Board/Institution/Council of
passed
Examination
Main
Subjects

Year of
Passing

Division
Percenta
/Class/
ge marks
Grade

14. Details of course for which scholarship is being sought: Name of the technical/professional course: BCA( Batchlor of Computer App ) Duration of course

3

Academic year

2012-2013

Hosteller

N

15. Basis of admission in professional/technical course (whether on the basis of qualifying competitive examination or on other grounds. Please give details):

16. Details of college/institution:
(i) Name of the college/institution
where admitted:

MOUNTAIN VIEW COLLEGE MANAGEMENT SCIENCEVIDYANAGAR

(ii) Address of college/institution:

(iii) Telephone no:
(iv) Fax no:
(v) E-mail address:
(vi) Is the college/institution recognized. If so the name of authority which has recognized the institution :
Kuvempu University
(vii) To which university is it affiliated/does it have
deemed university status :

Printed Date: 25-Oct-12

Page 2 of 7

17. For renewal of scholarship:
Name of examination passed
BCA( Batchlor of Computer App )

Year

Marks Obtained

Full marks

% of marks

2

489

700

69.8571

18. Total Annual course fee: 50900.00
(Break up of course fee such as tuition fee, library fee, examination fee etc. other than refundable deposits):
Sl.No.

Item

Annual fee

1.

Tuition Fee

18000.00

2.

Admission Fee

32900.00
50900.00

Total

19. Details of bank account of student:
Name of the payee (as in the bank accounts)
Name of the Bank
Full address
Bank
Branch

SYNDICATE BANK
I G Road Branch Chikmagal

District
State
Pin code

Branch Code number
Bank Account Number

09002210033887

Bank Account Number in words
Type of bank Account(Saving/Current)
MICR code of the Bank
Mode of Electronic transfer available in the Bank –
ECS/RTGS/NEFT/CBS/code number (if any);20. Annual Income of parent/guardian of the student: Rs. 11000 (specimen form of declaration of annual income is given at Annexure which is to be signed by the parent/guardian of the student and enclosed alongwith the application. In case parent/guardian are employed, income certificate from the employer may also be enclosed)

Printed Date: 25-Oct-12

Page 3 of 7

21.

Documents enclosed with the appplication:

(i) One copy of passport size photograph with signature
(ii) Attested certificates of educational qualification as filled up in para 11. (iii) Income declaration - affidavit on non-judicial stamp paper and income...
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