SHDF SCHOLARSHIPS 2021 (FOR NEW APPLICANTS)

NISHKAM SIKH WELFARE COUNCIL

In association with
SIKH HUMAN DEVELOPMENT FOUNDATION, USA

NISHKAM BHAWAN, B-BLOCK, TILAK VIHAR, TILAK NAGAR, NEW DELHI – 110018
Ph. No. 011-28333842/011-28333377, Email-ID: scholarships@nishkam.org Website: www.nishkam.org

INSTRUCTIONS / GUIDELINES / ELIGIBILITY CRITERIA FOR NEW APPLICANTS

READ CAREFULLY
REGARDING APPLICATION FORM:
1. Fill the Application Form clearly and completely in English (BLOCK LETTERS) IN YOUR OWN
HANDWRITING.
2. Please fill in all the columns with NO DOTS or DASHES.
3. NO COLUMN IS TO BE LEFT BLANK. INCOMPLETE APPLICATION FORMS WILL BE SUMMARILY
REJECTED and no further correspondence will be entertained.
4. Report from College Authorities on prescribed performa (2 pages), attached with application form duly signed by the
HEAD OF THE COLLEGE/INSTITUTE with DATE AND COLLEGE STAMP.
5. Ensure that duly filled in & signed Application Form along-with required documents must reach us on or before
30th September, 2021.
6. Application forms received AFTER THE DUE DATE WILL NOT BE CONSIDERED.
REQUIRED ENCLOSURES/SUPPORTING DOCUMENTS:
Attach the following documents along with filled in and duly signed by applicant & parent / guardian Application Form: -
1. Three recent photographs -Good quality colored passport size (Paste TWO photographs with your signature at
appropriate place in the Application Form and ONE (without signature) with your name on the backside of it in an
envelope to be attached to the form).
2. Mark sheets of 10th Class Examination, Sr. Secondary Examination & later exam, if any (Self Attested).
3. DMC /Attested copies of Gazette (for the Examinations passed during 2020-21) of professional courses. (exams
held before Jan, 2021)
4. Copies of Fees receipts paid for the academic year 2021-22(Self Attested). No handwritten Receipts will be
accepted.
5. Copy of Death certificate(s), if father/mother is not alive.
6. Proof of family income (both parents):- Must attach attested copy of latest Income Tax Return / Employer
Certificate/Pension Details mentioning yearly income, details of agricultural land acreage and annual income,. For
daily wage laborers, (Specify nature of work) small shopkeepers (specify type of shop), self-employed persons (who
have filed no income tax return) stating income from all sources as per appropriate enclosed format.
7. Photocopy of front page of the passbook or cancelled cheque leaflet having your name on cheque.
IMPORTANT INSTRUCTIONS:
1 Completed Application Form with all Enclosures should be sent to “Nishkam Sikh Welfare Council, Nishkam
Bhawan, B-Block, Tilak Vihar, New Delhi-110018” by speed/registered post or courier marking, “SHDF
Scholarships- 2021” on the top of the envelope containing application and must reach Nishkam Office latest by
30th September, 2021 (1700 Hrs.). Applications received after the last date will be summarily rejected.
2 Roll No. will be assigned by Nishkam to each shortlisted applicant which is always to be used alongwith your contact
number while communicating with Nishkam.

(This page is for your guidance please do not attach this page with Application Form)
 3 Candidates will be required to appear in Written Test in General knowledge and Punjabi language from the book,
“Naitik Sikhya” published by Literature Publication Department, Guru Gobind Singh Study Circle, Ludhiana and is
available on payment basis at Book Stalls. Each candidate is required to score a minimum of 50% marks in paper. Tests will
be followed by an Interview for successful candidates (Schedule for Written Test and Interview will be intimated and put
on web-site). Candidates will be required to bring their Admit Card and ID Proof while coming for the written tests and
interview.
4 Please give TRUE & CORRECT information. Giving false information or suppression of any fact will result in
termination of scholarship, if already granted and processing of other legal action. STUDENTS BELONGING TO
ONLY NEEDY FAMILIES SHOULD APPLY.
5 If the applicant has received financial assistance (either on account of SC/ST/OBC/ Any other category OR from any other
institute / source) during previous year or has applied or is expecting for this year, then complete information must be
provided in the Application Form as well as in the Report from College Authorities.
6 You may check the status of your Application at Nishkam website, “www.nishkam.org”. NO PHONE CALL WILL BE
ENTERTAINED IN THIS REGARD.
7 Please inform immediately of any CHANGE in your POSTAL ADDRESS or E-MAIL ID or PHONE NUMBER.
8 The management reserves the right to reject any application without assigning any reason. Decision of management for
scholarships shall be final and binding. No correspondence will be entertained in this regard.
9 It may also be noted that each student eligible for Scholarship will have to attend all Seminars / Workshops when invited for
his/her improvement of Communication skills, Personality Development, Moral Science, Human Values and Career
Guidance during the year. Please note that appearing in work shop is mandatory. If you have some valid reason for Non
appearing email us with sufficient proof well in time otherwise penalty will be imposed.
10. Please note that Transport charges, Hostel Charges and refundable charges will not be considered while calculating
scholarship. Scholarship will be calculated as per our norms and maximum amount of scholarship will be Rs. 33000/-.

ELIGIBILITY CRITERIA
These scholarships are available only for pursuing professional diploma, degree or postgraduate courses in a recognized
institution/University in India. The term professional course includes, (but is not limited to), engineering, architecture, information
technology, computer science, medical, nursing, pharmacology, home science, education, business management, agriculture, animal
husbandry and the like. Students appeared in Class X & XII Examination (Academic year 2019-20) can also apply and take the
Written Test and Interview, but the scholarship will be granted, if found eligible, only on getting admission for a professional course
in recognized Institute
(i) The applicant must have obtained at least 60% marks in the previous two examinations.

(ii) The gross family income of the applicant must not exceed Rs. 2,50,000/- per annum.

(iii) The applicant must maintain an active e-mail account for correspondence with Nishkam. He/she must mention a Mobile
and alternative telephone number for easy communication.
HOW TO APPLY
This is a five step process.
First Obtain / download the prescribed Application Form, which is available at Nishkam’s website www.nishkam.org .

Second Obtain/Collect necessary documents to be submitted with the Application Form as per the details given on first page.

Third Fill up the application, clearly and completely (with no dots, dashes and blanks), and send it, together with attested
photocopies of all certificates and receipt of fees paid and other necessary documents, so as to reach Nishkam office in
New Delhi (by mail or delivered personally) latest by 30th September, 2021. Incomplete Forms/ Forms received after
due date will be summarily rejected.

Fourth Applicants whose forms are found complete in all respects, will appear, at his/her own expense, in the written test to be
conducted by Nishkam (time and place will be notified separately) The admit cards for the written test will be sent on e-
mail. Schedule of written test and venue will be intimated through said admit card or at our website www.nishkam.org .

Fifth Candidates qualifying written test will appear for Interview, at their own expense. Date, time and venue for the interview
will be notified later on.
Please note that appearing in written test and interview is not a guarantee for sanction of scholarship

(This page is for your guidance please do not attach this page with Application Form)
DETAILS OF WRITTEN TEST
The written test consists of following two papers (in Punjabi language): -

Paper I: Elementary test in punjabi language will be from General Grammar and the students will have to prepare by self-
study. One question in English language (on any general topic) will also be asked.
Paper II: Religious and Moral studies will be from a book ‘NAITIK SIKHIYA’ published by Guru Gobind Singh Study
Circle, Ludhiana

The book NAITIK SIKHIYA , published by Guru Gobind Singh Study Circle is available on payment basis at book stalls
at the different centres in Punjab as per list appended below. The students from New Delhi may purchase the book from
Nishkam Sikh Welfare Council, B-Block, Tilak Vihar, New Delhi-110018.

For enquiry regarding availability of books please contact the Sewadars indicated below.
S.No.  Area  Contact  Mobile No./  S.No. Area Contact Persons Mobile No.
Persons  Telephone No. 
1  New Delhi  Ms. Simranjot  0‐11 28333842,  8 Chandigarh,  S. Manjit Singh  8872209922 
Kaur  0‐11 28333377,  Mohali    ‐‐‐  9417374491 
0‐11 28334477,  ‐‐‐  7986946264 
0‐11 28335577  ‐‐‐   
2  Ludhiana  M/S SUKRIT  9888266676  9. Hoshiarpur Navpreet Singh  8872010691 
Guru gobind  9888025960  ‐‐‐  9855173278 
Singh study       
Circle 
‐‐‐ 
‐‐‐ 
3  Amritsar‐Tarn  S. Gurjot  9914017038  10 Sangrur‐ S. Surinder Pal  9888499726 
Taran    Singh  9914017086  Mansa‐ Singh Sidki   
‐‐‐  9815415575  Barnala  ‐‐‐ 
‐‐‐    ‐‐‐ 
‐‐‐ 
 
4  Gurdaspur  S. Pritpal  9914409442  11 Patiala  S. Damanjit Singh 9501224411 
Singh     ‐‐‐  7508018905 
‐‐‐  ‐‐‐  9878084055 
 
5  Jalandhar  S. Bakhsis  9876750027  12 Ferozepur‐ S.   Kulwinder   9855504406 
Singh  9815583239  Moga  Singh  9855590860 
‐‐‐  9872076276  ‐‐‐  9855531875 
‐‐‐  7696233600  ‐‐‐   
‐‐‐   
6  Abohar‐Ganga  Dr. Mandip  9815923537  13 Faridkot‐ S. Harvinder Singh 8437221325 
Nagar  Singh  8872800538  Muktsar‐  ‐‐‐  9814900645 
‐‐‐  9915744143  Bathinda  ‐‐‐  8360623921 
‐‐‐   
‐‐‐ 
7  Ropar –  S. Tejinder   9888893879 
Nawan Sehar  Singh   9256232307 
‐‐‐  9417707099 
‐‐‐   

Last Date for Submission of Scholarship Application Form is September, 30, 2021
(This page is for your guidance please do not attach this page with Application Form)
 FORMAT “A”
(For Self owned business/shop/self employed etc.)
This declaration of income statement must be typed on a Stamp Paper and duly attested by Notary/Magistrate/Revenue
Authority
Affidavit on Stamp Paper is to be sent with the Application Form

AFFIDAVIT

I,________________________________________ son/wife of ____________________________ resident of ________

________________________________________________________________________________________________

and father/mother of _______________________________________(Name of Applicant), who is studying in _________

________________________________________________________________________________________________

do hereby solemnly affirm and truthfully give the following details that:-

1. I am a self employed person and running the business of ___________________________________________

2. The name of my business/shop is _____________________________________________________________

3. The address of my business/shop is ___________________________________________________________

4. The business/shop location is owned by ________________________________________________________

5. I deal in the following main commodities ________________________________________________________

6. My total annual income from this business/shop is Rs. _____________________________________________

7. I have ________ number of hired workers.

8. My PAN No./Sales Tax No. is _________________________________________________________________________

9. I am paying /not paying Income Tax _____________________________

(if paying attach copy of IT Return.)

I hereby declare and affirm that the information given as above is true and correct to the best of my knowledge and belief
and nothing material has been concealed or suppressed therein. I also understand that if the above facts and figures are
found to be false at any stage, then any financial benefit given to my son/daughter under the scheme of ‘SHDF
Scholarships’ could be withdrawn. Besides, legal action as per law can also be initiated against me or my ward.

Date __________ DEPONENT

Verification:
Verified that the contents of this Affidavit are true and correct to the best of my knowledge and belief and nothing has
been concealed therein.

Date __________ DEPONENT

(Send any one Format (from Format-A to E) which is linked with your Application Form)
 FORMAT “B”
(For Farmers/Agriculturists having own land)
This declaration of income statement must be typed on a Stamp Paper given below and duly attested by
Notary/Magistrate/Revenue Authority
Or
Self declaration duly attested by Village Sarpanch/Tehsildar
Affidavit on Stamp Paper OR Self declaration (whichever is applicable) is to be sent with the Application Form

AFFIDAVIT

I, ________________________________________ son/wife of ____________________________ resident of ________

________________________________________________________________________________________________

and father/mother of _______________________________________(Name of Applicant), who is studying in _________

________________________________________________________________________________________________

do hereby solemnly affirm and truthfully give the following details that:-
1. I own _________ (land size) _____________ of agricultural land.

2. I have given on lease/rent _________ (land size) _____________ of agricultural land.

3. My agricultural land is situated at (complete address of where land is situated)_______________________

_______________________________________________________________________________________

4. I cultivate ___________(names of crop cultivated)_________________________ crops on this land.

5. My irrigation resource is ___________ Own Tube well/Canal/any other source ________________________

6. I have ______ nos. of Cows/buffalos and income from selling milk is ________________________________

7. My annual income from the sale of the crop and milk is Rs. ________________________________________

8. I have ________ number of hired workers working on my land.

I hereby declare and affirm that I have knowingly and willfully stated the above facts and the information given is true
and correct to the best of my knowledge and belief. I also understand that if the above facts and figures are found to be
false at any stage, then any financial benefit given to my son/daughter under the scheme of ‘SHDF Scholarships’ could be
withdrawn and legal action, as deemed fit, may be initiated against me or my ward.

Date __________ DEPONENT

Verification:
Verified that the contents of this Affidavit are true and correct to the best of my knowledge and belief and nothing has
been concealed therein.

Date __________ DEPONENT

(Send any one Format (from Format-A to E) which is linked with your Application Form)
 FORMAT “C”
(For Labourers/Private Workers/Daily Wagers)
This declaration of income statement must be typed on a Stamp Paper bearing given below and duly attested by
Notary/Magistrate/Revenue Authority
Affidavit on Stamp Paper is to be sent with the Application Form

AFFIDAVIT

I, ________________________________________ son/wife of ____________________________ resident of ________

________________________________________________________________________________________________

and father/mother of _______________________________________(Name of Applicant), who is studying in _________

________________________________________________________________________________________________

do hereby solemnly affirm and truthfully give the following details that:-

1. I work as a labourer/ private worker OR _________________________.

2. My nature of work is (Describe it)____________________________________________________________

_____________________________________________________________________________________________________

3. My monthly Income as Labourer/Private Worker/ ______________ is Rs.______________________________

4. I have my own house.____________________YES / NO __________________________________________________

I hereby declare and affirm that I have knowingly and willfully stated the above facts and the information given is true
and correct to the best of my knowledge and belief. I also understand that if the above facts and figures are found to be
false at any stage, then any financial benefit given to my son/daughter under the scheme of ‘SHDF Scholarships’ could be
withdrawn and legal action, as deemed fit, may be initiated against me or my ward.

Date __________ DEPONENT

Verification:
Verified that the contents of this Affidavit are true and correct to the best of my knowledge and belief and nothing has
been concealed therein.

Date __________ DEPONENT

(Send any one Format (from Format-A to E) which is linked with your Application Form)
 FORMAT “D” 

(For Salaried people etc)

This declaration of income statement must be typed on a Letter head of the company and duly attested by Employer
(in case of employee )
Declaration is to be sent with the Application Form

It is hereby certified that Sh./Smt. ____________________________ son / Wife of __________________________ is an

employee of our Company / Organization since ____________ in the position of _______________________ and drawing a

monthly salary of Rs. ___________. His/Her monthly Salary Slip is Attached.

_______________________________

(Signature, Designation & Seal of the issuing authority)

Date __________

FORMAT “E”
(For Pensioners etc)
This declaration of income statement must be printed on a Letter head of Bank where you are receiving pension and
duly attested by Bank Manager
Declaration is to be sent with the Application Form

It is hereby certified that Sh./Smt. ____________________________ son / Wife of __________________________ is a

Pensioner and he/she is getting Rs ____________ per month as a pension in our Bank. Copy of his /her bank passbook is

attached herewith.

_________________________________________

(Signature, Designation & Seal of the issuing authority)

Date __________

(Send any one Format (from Format-A to E) which is linked with your Application Form)
 APPLICATION FORM FOR SHDF SCHOLARSHIP 2021
(For new applicants)
To be submitted to
NISHKAM SIKH WELFARE COUNCIL
Nishkam Bhawan, B-Block, Tilak Vihar, Tilak Nagar, New Delhi-110018
Tel. : 2833-3842/6677/5577/4477/3377, Website: www.nishkam.org

STUDENTS BELONGING TO ONLY NEEDY FAMILIES SHOULD APPLY.

Roll No. Paste passport size

(To be filled in by Office) photograph (do not
staple) The candidate
Encircle Test/Interview Centre of your Choice: should write his/her name
& sign across the
AMRITSAR / CHANDIGARH / FARIDKOT / MOGA / BATHINDA / LUDHIANA / NEW DELHI / HOSHIARPUR / SHAHBAD photograph

1. Full Name (in Capital Letters) _________________________________________________

2. Date of Birth(DD/MM/YYYY)_____/_____/______ 3.Religion ____________3a. Whether belongs to SC / ST / OBC / General 4. Gender ___________
(Tick any one)

5. Contact No.(s)_________________________________________ 6. Valid Email-ID __________________________________________________________

7.Permanent Residential Address(in Capital Letters):______________________________________________________________________________________

____________________________________________________________________________________________________________________________________

District________________________________Tehsil___________________________________ State__________________________Pin Code_________________

8. Residing in Rural Area or Urban Area ______________________

9. Family Particulars:

(A) Parents Father Mother

(i) Name

(ii) Education/Technical qualifications

(iii) Occupation/Profession

(iv) Annual Gross Family Income (Please provide proof)

(B) Brothers/Sisters living with Parents:

Name Relation Age Class/Course of study Tuition fee(Attach proof) If working
(Brother/Sister) (If studying during 2021-22) (Annual) (Profession and Income)
1.____________________________________ __________ _____ __________________ _________ _______________
2.____________________________________ __________ _____ __________________ _________ _______________
3.____________________________________ __________ _____ __________________ _________ _______________

10. Were you ever rusticated /reprimanded /fined /debarred from appearing in any examinations in any year? Yes/No.___

10a. If Yes, give details :

________________________________________________________________________________________________________________________________
Page No.-1/6
11. Did you receive or do you expect to receive any Financial Assistance from any other source for the course for which SHDF scholarship is requested?
(Yes/No)

If yes, then give particulars including the amount and duration of such assistance:
Name of the Source from which Assistance received/expected. Duration
Total Amount
Month, Year to Month, Year
   
 
 
 
12. Particulars of Examinations Passed (Please attach copies of certificates):
Details of the School/Instt.
Medium
Month/Year Total Marks
Exam Percentage (Hindi/English
(MM/YYYY) Marks Obtained Name & Address Govt. / Aided /
/ Punjabi)
Unaided / Pvt.
Sec. Exam (X)

Sr. Sec. Exam (XII)

Others(Please specify)

13. Academic Record of last four semesters or two years (wherever applicable):

Course of study(start with the Maximum no. of

latest exam) Semester/Year Marks obtained Percentage Month & Year of Exam
marks

14. Planned Programme of Studies:

Students pursuing professional Diploma/Degree/Post Graduate courses in universities/ affiliated colleges; Institutes of national importance or Deemed Universities are
eligible for scholarship. (Correspondence courses are not eligible)
Duration Date/Month/Year of Details of the College/University
Course for which
Name & Address Govt. / Aided / Year/Semester in which
Scholarship is Admissi Compl Unaided / Private studying at present
Requested on -etion

15. Achievements, Interests & Hobbies:

National Talent Scholarship or any other Medal/Certificate of Merit in

Hobbies
Scholarship/Medal, awarded to you sports/athletics/other

16. References: Give details of two persons(not close relatives) who know you well and can provide information about you.
Name  Address  Phone No. Email‐ID 
1)   
   
   
 
2)   
 
 
 
Page No.-2/6
17. Justification for grant of scholarship being given:
State in not less than 200 words in English/Punjabi (If less than 180 words application would be deemed incomplete and will likely be rejected): (a) What is
your goal in life? (b) How will the scholarship from Sikh Human Development Foundation, USA help you to achieve your goal? You may highlight your early
schooling, parents’ background, challenges (how you have overcome them), achievements among others. If required, attach a sheet of paper to answer these questions.
Please write your Roll Number, Full Name and attach to the application.
________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

I have attached an additional sheet.(Yes/No)

18. Details of Bank account:

Applicant Name (Name as per passbook) :_________________________ Bank Name:_______________________________

Branch Name:_____________________________ Account Number:___________________________IFS Code :____________________

19.Family Occupation and Assets:

(i) Please tick mark the main occupation of your family (for both mother and father):
Occupation  Father  Mother  Income Proof to be submitted with Application Form‐Please submit in the appropriate format
Businessman Copy of latest ITR (if Filed) or income proof as per FORMAT-A

Farmer(having own land) Income Certificate as per FORMAT-B

Labourer Private Workers/Daily Income certificate as per FORMAT-C

Wagers
Employee Copy of latest ITR (if Filed) or income proof as per FORMAT-D
Pensioner Proof of receiving pension as per FORMAT-E

_________ ____________

Page No.-3/6
 (ii) Please tick mark the assets owned by your family (if more than one, give number ):
House _____ Car _____ Motorcycle/scooter _______ Television Set ________

Tractor _____ Truck ___ Auto Rickshaw ________ Tubewell __________

House for Rent ____ Shop ______ Any Other (Please Specify)__________________________

(iii) Tick mark the Agriculture assets owned by your family:

Agriculture land : (If Yes, state the number of acres owned________________________)

Livestock : (If yes, Give number of cows _____ buffaloes ______others _______)

19. How did you come to know about this scholarship: Friends / Relative / Advertisement / Nishkam Website / School / College /Centre Head / other
(Please specify) ______________

20. Declaration/Undertaking by the Applicant (Duly supported by father/guardian):

(i) I hereby declare and affirm that the information given above is correct, and no material information has been
withheld /concealed. I will also maintain my e-mail account/contact number to be able to remain in touch with Nishkam, SHDF and others.
(ii) I clearly understand that higher professional education is the best tool to empower our youth to lead a life of dignity and honour, but many of them,
like me, cannot afford the tuition and other college expenses unless helped with scholarships. I hereby commit myself on oath that, in response to the
scholarship help given to me, I will regularly contribute my services/time and part of earnings, to support our youth to get access to higher
professional education. This Sewa is my creative social responsibility as well as my moral duty and I will never shirk from it.
(iii) I do hereby give my unconditional consent for disclosure of information related to me to any communication channel, by the Nishkam Sikh Welfare
Council, New Delhi.
(iv) I understand that giving any false information in the application and attachments may result in termination of scholarship and NSWC reserves the
right to recover the scholarship amount already dispersed.
(v) I will attend all Guidance & Counseling Activities/Programs/Workshops organized for SHDF scholarships, to which I am invited.
(vi) I do accept all the rules and regulations of the SHDF scholarship program as applicable from time to time.

_________________________________ _________________________
Signature of Father/Mother/Guardian Signature of Applicant

Name:________________ Name:_____________________

Date:_________________ Date:______________________

21. Checklist:
Please tick appropriate box with ( ) or ( X) and / or fill-in relevant information in the space provided for the following check-list points (Also attached
the documents in the same sequence):

S.No. Check list Point Yes ( ) No (X) Reason for No (X)

1. 3 Photographs pasted / attached
2. Duly Filled & signed Application form from page No.-1-5 along with valid and
working Mobile Number and E-mail ID
3. Duly filled and signed Report from College Authorities (2 pages) showing
breakdown of tuition and other fees for the academic year 2021-22.
4. Self attested photocopy of Mark sheet for Class X
5. Self attested photocopy of Mark sheet for Class XII
6. Self-Attested Gazette / photocopy of DMC for Examinations passed during April
2020- December 2020 of professional course.
7. Self attested Photocopies of fees receipts already paid for the period from June
2020 onwards (from June 2021 onwards for First Year Students)
8. Latest, Original Annual Income Proof.
9. Photocopy of front page of the passbook or cancelled cheque leaflet having your
name on cheque.
Page No.-4/6
 IMP – TO BE SUBMITTED ONLY AFTER GETTING ADMISSION
SHDF SCHOLARSHIPS: 2021(for new applicants)
REPORT FROM COLLEGE AUTHORITIES

Name of the student: _______________________________________________________________

Paste passport size
photograph (do not
S/o / D/o ___________________________________________________________________________ staple)The candidate
should write his/her name
& sign across the
photograph
Address : ______________________________________________________________

______________________________________________________________

District__________________________Tehsil__________________________

_________________________________Pincode ________________________

Phone No(s). ________________________________ Email-Id _____________________

Name of the College / Institute   
 
 
Address of the college / Institute   
 
 
Name of University   
 
 
Name of the Principal / Head of Department   
 
 
Phone No. & Email address of the Principal / Head   
of Department   
 
 
Family’s annual Income as per college / Institute   
record   
Receiving financial aid / Scholarship from any other   
Organization? If yes,  
1) Name of the organization and  
 
2) Amount for the academic year  

---Continued on next page----

Page 5/6
 ---Continued from previous page----
Student’s Details for Academic Year 2021-22:
Duration of the Year/Semester in Conduct
College/Institute Year of
Course Of Study course/No. of which studying at (Satisfactory/Not
Roll no. admission
semesters/years present satisfactory)
           
 
 
Previous Years’/Semesters’ Academic Record of Student, if applicable,
Two most recent
semesters or one year Maximum Marks Month & Year of Subject(s) in which required to
Percentage
(Start with the latest Marks obtained Examination reappear , if any
Exam)

Details of Fee chargeable by the College & paid for academic year 2021-22 (Provide copies of paid receipts)

Concession Actual Fees paid for year

Net fees including
given by 2021-22
S. any concession for Balance Fees (to be
Item the college
No. Academic Year paid)
(if any)
(2 Semesters) 2021-22
Amount Receipt No. & Date
1. Tuition Fee

2. Development Fee

3. Examination Fee

4. Others (Please specify)

__________________

5. Total (Sr. no. 1 to Sr. no.-

4)
(a) Transport charges
(b) Refundable Charges

(c ) Hostel Charges

Grand Total (5 + a + b +
c)
Certified that the above information in respect of _______________________ (Roll no.__________), S/o, D/o
________________________________ is as per official record of the College/Institute and has been provided to facilitate grant of
scholarship to the student.
Date _____________

Place_____________
(Principal/ Head of Department)
(Stamp of College/Institute)
Page 6/6