INDIAN INSTITUTE OF TECHNOLOGY ROORKEE

APPLICATION FOR GRANT OF Merit-Cum_Means (MCM) Scholarship FOR THE SESSION 2014-2015

Name:DHANANJAY LEKSHMI

NARAYANEnrollment No: 14115038

Class: B.Tech. Branch: EE

Semester: UG10 Category: Other Backward Classes

SGPA (Last Semester): None CGPA: None

Bhawan: RJB Room no: AF 034

Mobile No: 94410987722 Email id: don283978@gmail.com

Penalised due to unfair means/ indiscipline: No

Bank: Account No.:

Permanent Address: KRISHNA KRIPA SARAS KORATTIKARA POPERUMPILAVU KERALA

Father's Information

Name: SUBRAMANIYAN T V Occupation:

Annual Family Income : None Rs.

I declare that the particulars mentioned above are correct. I herewith the latest parental income certificate(Mother

and Father both) in the prescribed form. If I get any scholarship/financial aid from any other source, I will intimate

the amount of scholarship. I understand that if any of information supplied is found to be incorrect, the amount of

scholarship, if any, received by me will have to be refunded and the institute can take any action against me as it

may deem fit in the regard.

Signature of Student

Jan. 14, 2015, 6:24 p.m.

Enclosures:

1) Hard copy of computer generated application form.

2) Affidavit from all family members regarding income.

3) Income certificate signed by Revenue officer.

4) Photo copy of last semester Grade Sheet.

5) JEE Advanced-2014 rank card (only for first year students).