7/21/2019 Application

http://slidepdf.com/reader/full/application-56dd0d40b7e4c 1/3

 APPLICATION FOR SCHOLARSHIPS

(For the Year 2015)

A. PERSONAL PARTICULARS

1. Name:

2. Roll No: 3. Semester: 4. Date of Birth:

5. Branch of Study: 6. Department:

7. Name of Faculty Advisor

8. Permanent Home Address:

City: Pin:

State:

Phone No.(with code):

9. Hostel/Local Address:

e- mail id:

Saving Bank Account No:In State Bank of India(SJET Scholarships are given directly throughsaving bank account in SBI)Contact Phone No:

10. Quota against which admitted:

a) State: Yes / No b)other criteria:

NATIONAL INSTITUTE OF TECHNOLOGY CALICUT

RE Silver Jubilee Endowment Trust

NIT Campus (P.O), CALICUT – 673 601, KERALA

 Affix your recentphotograph here

B. FAMILY PARTICULARS

1. List of members of family and their monthly income

Monthly Income (Rs.)Sl.No.

Name Relationship Age OccupationSalary

Othersources

Total of the monthly income of all the members taken together=

2. Details of employment (name of the dept. / firm etc.) and details of job / occupation of parents

-1-

7/21/2019 Application

http://slidepdf.com/reader/full/application-56dd0d40b7e4c 2/3

  -2-

3. Details of other Scholarships / financialassistance that you are in receipt or have appliedfor (name, amount, period etc.)

4. Particulars of landed properties, rental buildings,business etc. of family members

5. Give full details on how the expenses of yourstudies were met during the previous years

6. Details of the staff / faculty of NIT Calicut, whoknows your academic & financial background(Name, Dept. / Section & Phone No.)

7. Give name, official address and phone number ofone responsible person (like Principal/ Teacherof the school/college in which you have studied,Official of Revenue Dept. /Panchayat etc.) towhom we can refer and get your financial andacademic background

C. DETAILS OF SCHOOL/COLLEGE ATTENDED (from matriculation onwards)

CourseStudied

Name & Address ofSchool/College

Period of StudyFrom To

% of Marks/Grades

Class/Distinction

 

Marks/Grades obtained for Mathematics, Physics, Chemistry in +2 Exam:

 AIEEE Rank obtained - All India Wise: State Wise:

Other admission criteria, if any:

D. ACADEMIC PERFORMANCE AT NITC

Semester SGPA CGPANo. of

Subjectsfailed, if any

Semester SGPA CGPA

No. ofSubjectsfailed, if

any

I VI

II VII

III VIII

IV IX (B. Arch)

V X (B. Arch)

Co- curricular activities :

7/21/2019 Application

http://slidepdf.com/reader/full/application-56dd0d40b7e4c 3/3

  -3-

E. DECLARATION

a) DECLARATION by the student:

1. I certify that all the information given in parts  A  to D of this application is true to the best of myknowledge and belief.

2. I am aware that disciplinary action will be taken against me, if it is known, even at a later stage, thatI have furnished wrong information or withheld relevant information asked for.

3. I understand that financial assistance from the Silver Jubilee  Endowment Trust / PTA / NITC

Hostels  is intended for students who are economically backward  and who do not have othersources of financial support.

4.  If I am awarded financial assistance, I shall strive best to  excel in studies. I will consider this as agreat help and treat it as a loan and  I assure you that I shall pay back to the institute, when I am

employed/start earning so that more students will benefit out of this scheme.

Date: Name: Signature:

b) DECLARATION by the Parent:

1. I certify that I have gone through the application and I am convinced that all the particulars given bymy son/daughter/ward Mr./ Ms.………………………………………………………. are correct.

2. I certify that the maximum monthly payment which I can afford for the education of myson/daughter/ward, considering all sources of income is Rs……………

3. Any other relevant information which the parent/guardian would like to give:……………………………………………………………………………………………………………

Place: Signature of the Parent:

Date: Full Name, Address, Phone:

Note: Original of the following certificates is to be produced on demand:(Copies of the certificates are not required along with the application.) 

1. Matriculation/Equivalent Mark/Grade sheet2. +2/Equivalent Mark/Grade sheet3. Entrance rank certificate4. Degree mark list5. NITC Semester Grade sheets6. Income certificate from Village Officer/Tahsildar/Employer (with official seal)

F. RECOMMENDATION by  

1. Faculty Advisor(With Name & Signature)

2.  Head of the Department is requested to allot a global priority number   to theapplicant in the Department, after getting all the applications. (Feed back from FAs,academic performance, financial condition etc. may be considered for this.) 

Global Priority No. in the Dept.: Signature of HOD: 

G. FOR OFFICE USE