I

To

The DirectorDepartment for Welfare of OBCs

Government of Tripura.

APPLICATION FORM FOR SANCTION OF POST MATRIC

SCHOLARSHIP FOR OBC STUDENT

Photo withsignature ofthe Student

Through...... ...,.schoot/coilege/f@

subject:- Application for sanction of post-Matric scholarship(Fresh/Renewal).

Sir,

I wor-rld like to apply fbr sanction of Post-Matric Scholarship fbr the academic year 201 6to2017 in

m1- f'avour. necessary particr-rlars in support of rny clairn fbr sanction of Post-Matric Scholarship have

been given in part -1, Parl - Il, Part- III. Part - IV of this application fbrm. I also indicate of the coltrse

name and mentioning the present colrrse year

.... in support of Sanction of Scholarship.

lalso bring to your kind notice that presently I have been studying the said course of 1't year/ 2nd

Year/ 3'd Yearf 4th Part (Tick which is applicable).

I would therefore, request you kindly to sanction "Post-Matric Scholarship" in favour of me for the

aforesaid academic year.

Yours faithfully

(Full signature of the application)Duration period of entire Course.........Present Course yea r.............Roil No.........

School/College Name......Bank Account No of the Candidate.......................Bank Name with BranchAadhar No. of the Candidate..................,...Bank IFSC code no.......

(Must be filled up by the student)

toRM 1

(To be filled by the student) Part -1

7. Full Name Of the Student:(ln Block Letters)

2. Father's / Mother's name

3" i) Permanent Address of the student:(Attach a attested copy ofthe PermanentResident Certificate)

ii) Present address of the student:

iii) Contact No. ofthe studentAnd Guardian: e-mailaddress of thestudent:(lf any)

iv) Nationality of the Student:

v) Name and address of the institute withcontact number, fax number, e-mailaddress:

vi) Bank account number of the student withname of Bank, Branch name and BranchIFSC code:

4. i) Name of Guardian (ln case of death ofFather,Mother is the Guardian and in caseof death of both the parents the name ofthe Legal / Local Guardian)

ii) Relation of the student with the Guardian:

iii) Permanent Address of the Guardian:

5. i) Name and Address Of the Local Guardian:

ii) Relation of the student with the Local

Guardian:

5. i) Strea m/Course of Study:

ii) Percentage of marks obtained in the lastexam:

7. i) Whether the application belongs to OBC: OBC(Please strike out in applicable portion)

ii) Name of the caste to which the applicantbelongs:(An attested copy ofthe caste certificateissued by the SDM to be enclosed)

8. i) Whether the applicant stayed in a hostelattached to school and if so the date ofadmission and name of hostel:

Yes/No

ii) Whether the applicant attend the classfrom his own residence:

Yes/No

iii) Approximate distance of the applicant'sresidence from the school:

ln km

iv) Whether the applicant stays in a hiredaccommodation used as a mess, lf so thedate from which he stays there :

v) Full address of the hired accommodationused as a mess:

9. i) Whether the father of the applicant is inany Govt. Non-Govt. service, if so hispresent basic pay and total annual salary(Pl. Attach income certificate from DDO):

ii) Whether the mother of the applicant is inany Govt. Non-Govt. service, if so herpresent basic pay and total annual salary

(Pl. Attach income certificate from DDO):

iii) lf father or mother is not in any service thesource of income of the applicants familyand total annual income.(lncome certificatefrom SDM/Dy. Collector to be attached):

iv) Number of children of the parent receivingscholarship:

Signature of the Student

List of enclosures.

1. Attested copy ofthe student's P.R.T.C /Copy of Bank Pass Book/ Aadhar card certificate/prof ofAdmission certificate / Fees structure of the Course.

2. Attested copy of student's Nationality Certificate.3. Attested copy of student's caste Certificate.4. Attested copy of student's Family income certificate.5" Attested copy of student's Mark Sheet.

Declarqtion No.-!

(To be signed by the Student in the presence of gazetted officer)

P.O. TripuraDistrict,

hereby declare and affirm that the particulars given in Part-ll of this form are true to the best of myknowledge and belief and in case any of the particulars furnished is found to be false at any subsequentstate, I shall be bound to refund to the Government the entire amount of post- Matric scholarship paidto me either in lump sum or in installment as the sanctioning authority may direct. I shall also be liableto other actions which the School/College/University authority may take against me.

(Signature of the applicant inPresence of gazetted officer)

Declaration : ll

(To be signed by the father mother guardian in presence of a gazetted officer)

I

Sri _ S/O

- father / mother /guardian (guardian only in case parents are not alive) of the applicant Sri do hereby

declare and affirm that I have personally verified the particulars furnished by me ward part-ll of theapplication form and that they are true to the best of my knowledge and belief and in case any of theparticulars furnished in this application form is found to be false at any subsequent stage, lshall bebound to refund to the Government the entire amount for Post- Matric Scholarship paid to my wardwhether in lump or in installment as the sanctioning authority may direct. I shall also be liable to otherlegal action.

(Signature of the father /mother /guardian of theApplicant in presence of a Gazetted officer)

Date :

Place :

) certify thatSri

P/s

Date:Place:

has signed the above declaration in my presence.

(Signature. name and sealof the gazetted officer)

L.

PART-IV

(To be filred by the Head of tnstitution)

The applicant Sri/SmtPassed the last examination and obtained

-%o

marks as per particulars given at columnNo-6.

The applicant belongs to OBC is applicable only for the students as per particulars given atcolumn 7.

The annual family income of the applicant is Rs (Rupees

)only as per particulars given at column no-g.

4. (i)The applicant stays in hotel mess as per column No_g(ii) The distance of the applicant's permanent residence from the Educationat lnstitution, it isapproximately kms.

As hosteller pursuing study in=--.-- group(mention Group A,B,c,D and E as the casemay be)

Whether the concerned lnstitute are affiliated to the TBSE/CBSE/ICSE etc. tf so should mentionthe name of the authority along with indicate vide orderl\o. (Attached affiliation copy wtth thea pplication)

Name of Class/Course :

Duration of study :

Academic Year :

Total Annual Fee & Other charges in Rs:

(Break up of course fee such as tuition fee, library fee, examination fee etc. Other thanrefundable deposits if any applicable)

Sl. No. Item Annual fee

Total :

(Please strike out inapplicable column)(Signature of the Head of the

I nstitution/Col lege/U n iversity)

2.

3.

5.

6.

DETAILS OF POST -MATRIC SCHOLARSHIP ARE BEING SOUGHT

FORM -2For Digitization

Pos! Matric Scholarship for OBCs

1 Full Name ln English

2. Full Name in Recognized Official Language

3. Gender

4 Address'1 (House NumberA/illage/Colony)

Address 2 (VillagetuVard)

6 Address 3 (Gram PanchayeVTown)

7. Address 4 (District)

8. Address 5(Staie) TRIPURA

L Pin code

10. Aadhar No.

11 Account Number

Bank Name

13. IFSC code of Branch

14. Academic Year

15 lnstitute( Full Name in English)

16. State Amount in Rupees

17 GOI Amount in Rupees

1B Day Scholar/Hosteller

10 Additional Allowances Rate Per Month

20. Additional Allowances Number of Month

21 . Group A to D

22 Maintenance Rate Per Month

tJ_ Maintenance Number of Month

Thesis Typing Charge

)q Book Allowance

26. Non Refundable Charges

27. Study Tour

Signature if the student

N.B : Column 1 to 15 must be filled up by the Student

Signature of the Head of the lnstitution