Administration ofDadra and Nagar Haveli, UT.,

@irectorate of Education)Silvassa

No. EDN/cNL/svy (2oLZ - r8l / 2ota / I o 7 e) Dt. t/-12-20t8

ADVERTISEMENT(SARASWATI VIDYA YOJNA)

Applications are invited under Saraswati Vidya Yojna for Re-imbursement of fees

to girls students for the Academic Year 20t7-18 (Round-II) who are pursuingDiploma/Post Graduate Diploma/Graduate and Post Graduation level professional coursesasunder:-

l) 50%o fee re-imbursement to girl Students whose parental annual income is above

Rs.1.00 laktr.

2) 100% fee re-imbursement to girl students whose parental annual income is belowRs. 1.00lakh.

The application form can be downloaded from the website of D&NH i.e

www.dnh.nic. in and www.rmsadnh.webs. com.

Application completed in all respects should be submitted by registered post/Speed

post/By hand along with mandatory documents to the following address on or beforelr

lS lorlrQ, . (Applicants submitting their application form by hand should visit in

Note:- No applications forms willcircumstances.

Directorate of EducationI't Floor, Building No.5,PWD Office Complex,Silvassa -396230D&NH

be accepted after tS J ot 12013 under any

,,&r,*Director ( Education)Email: doe-dnh@nic.in

Fhone No. 0260-2642098

office hours.)

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Ph.No. 0260-2642098

No. EDN/cNL/ sw 12077 -t9l / 2oL8 / l&B)

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Income Limit below one Lakh (Tick):-Yes

SARASWATI VTDYA YOJANAAPPT,ICATION FORM

FOR ACADEMIC YEAR 2017-18 (ROUND-II)

Application No.:-

(A) (fo be filled Girl Students Last Date: -201E

1n) Applied for "Sareswati Vidya Yojana" Scholarship in for 2017-18 (Round I):

PART-A(to be filled by the Girl Student)1.Full Name of Girls student ( Please write in block letters)

SurnameFirst NameMiddle Name

Affix a passport sizephotograph

Yes No

50% of fees Re-imbursement(whoseparental income is

above Rs. 1.00 lakh

Admissible 100% of feesRe-imbursement(whose

parental income isbelow Rs. 1.00 lakh

2. Full Name of Father ( Please wrlte ln block letters)

3. Full Name of Mother (Please write in block letters)

4. Date of Birth (Please write as per SCC Certificete)

Community(Tick):i) sc tii) sr iii) oBC iv) Minority v) Others

6. Phvsicallv Handicanoed(Tickl:Y.; l-*l N" l-lMarital StatusMarried I--l single f-l Divorced f-l

7.

8. Address for correspondence:[Iouse No./FlatNo.

Street{Faliya

Village & P.O.

itylTown

District

UT/StatePin Code

Iele,MobileNo.

STDCODE

E-Mail ID

9. Nationality:

10. Religion:

(,\'o'

11. Domicile of Dadra & Nagar Haveli(Tick):Yes No l-_l

12. Aadhar Card No:

13. Particulars of Qualifying Examination:

ExaminationPassed

Month&Year ofPassing

Name of theSchooVCollege

Board/University

MarksObtained,/outofTotal marks

PercentageNo. ofattempt

S.S.C.E

H.S.S.C.E

Diploma

Sraduation

PostGraduation

Doctorate

14. Period of schooling in this U.T (Schooling Certificate of last 05 years continuous studyincluding the year of SSC/HSSC Examination from PrincipaVllead Master to be attachedwith the application)

Sr.

No. Standard Name of the SchoolAcademic

YearPassed in

Yearl. VIII

11. D(

lll. x

lv. XI

XII

15, Details of Current College/Institute and Course:-i. Name of the College/Institute where Girl student is pursing Diploma, P.G. Diploma

Graduation/post graduation course.

ii. Type of College/Institute)(Tick):

1a) covernment I | (b)Grant-in-Aid I (.)s"r-rin.n.u I (d)Autonomousl I

.)fiii. Address of Collegdlnstitute:

iv. Telephone number with STD Code:

v. Fax number with STD Code:

vi. E-mail ID:

vii. Name of the Course:

viii. Duration ofthe Course:

ix. YearlSemester of the Course:

a) Saraswati VidyaYoiana

b) Post MatricScholarship

2. Course of study forwhich scholarship wasgiven

3. Name of the institutionwhere student studied

x. Total corrse fees paid for the Academic year (original Fee receipt to be attached \ ith theapplication)

Receipt No. Dated _ Amount Rs.Receipt No. Dated _ Amount Rs.Receipt No. Dated _ Amount Rs.Receipt No. _ Dated Amount Rs.Receipt No. Dated Amount Rs.

"16. whether scholarship was availed undet the scheme or any other scheme in theprevious year (If yes, then indicate the below details.)

1. Name of the ScholarshipScheme

v""l-_l N" [--lvesl-_l No[__l

c\"'PART-B

(Bank Details of the applicant and check list of mandatory documents)l. Details ofBank Account ofStudents:

i) Name of Girl Student (As per bank passbook):

ii) Name of the Bank :

iii) Branch Name :

iv) Saving Bank Account Number :

vi) Bank IFSC No. :

(Two photocopy ofBank Pass Book to be attached with this application)

2. Following documents to be enclosed with the application

(a) Selfattested copy ofSSC Examination Mark sheet Yes No

(b) Selfattested copy of SSCE Attempt Certif,cate f.omH.M. of school

Yes No

(c) Selfattested copy ofHSSC Examination Mark sheet Yes No

(d) Self attested copy of HSSC Attempt Certifrcate fiomPrincipal of Schogl

Yes No

(e) Selfattested copy ofBonafide or Schooling Certificatestating continuous last 05 years ofstudy in D&NH

Yes No

(f)Self attested copy of Dependent Certifrcate fromMamlatdar, Dadra & Nagar Haveli, if claiming to beunder guardianship

Yes No

(h)In case of Central Gort. fmptofe -attestea copy otControlling Oflicer regarding continuous 05 years servicerf parents in this UT of D& NH.

Yes No

(i) Income Certificate duly issued by Mamlatdar, Dadra &Nagar Haveli for the financial year 2017- I 8

Yes No

(k) Original fee receipt from the College / Institute for theAY 2017-18

Yes No

(D Two attested copy ofaadhar seeded bank pass bookwith IFSC No.

Yes No

(n) Self attested copy of fees structure as approved &rotified by the Competent Authority of College/lnstitute

Yes No

(o) Selfattested copy ofAadhar card (12 Digit Numberissued by the comp€tent Authority ofGovt. oflndia)

Yes No

(g)

Self attested copy of 12 years p"rmane"t ResidenceCertificate of parents or Domicile of parents. In caseFather/l\4other is not alive, Guardian,s permanentResidence Certificate or Domicile from Mamlatdar,Dadra & Nagar Haveli.

Yes No

(i)

In case ofCentral Covt. gmployeeittesGdiopy of,ontinuous 5 years Permanent Residence Certificate of:arents from Mamlatdar, Dadra & Nagar Haveli

Yes No

(p)Self attested copy of Academic year 2017-ltexamination Mark sheets of Diploma / Graduation / postgraduation course

Yes No

cu3.

(D

(iD

(iii)

Declaration/Undertaking by the girl student:

I hereby declare that the information given above is correct.

I am not availing any other scholarship for this purpose from any other source.

I shall abide by the terms and conditions for sanctioning soyo of fees

Re-imbursement (whose parental income is above Rs. 1.00 lakh ) and l00yo

fees Re-imbursement (whose parental income is below Rs. l.00lakh).

(iv) I undertake that if, at any stage, it is found to the sanctioning authority in the

concemed State Government/ Union Territory Administration that the information

given by me is false or if I have violated the terms and conditions of the fee Re-

imbursement scheme, the re- imbursement sanctioned to me, may be cancelled and

the entire amount of re-imbursement will be refunded by me or recovered from me or

recovered from me with rate of interest as per the Government Rules.

Note:-Eligible girl students are directed to apply only one scholarship i.e. 50 %incentive to girl students OR Post Matric Scholarship (Centrally Sponsored Scheme

by GoI)

Date:

Place: SILVASSA

( Name and Signature of Girl student)

(Name and Signature of Father/Guardian)

(Name and Signature of Mother/Guardian)

c\70

Annexure - I(To be lilled by the Coltege/Institute)

1. Details of Fees paid by Girl Student in the College/Institute:

2. Certified that:

(i) lnformation given by the applicant in part-A and information stated abovehas been checked and found correcUhas been corrected in red ink.

(iD This Institutior/College Is affiliated by(Central Govemment/State Govemment AJT Government)

(iii) The applicant is studying in _year of_course in thisInstitution/college and the minimum qualification required for admissionto the course is and duration ofthe course is year.

(iv) The course ofthis College/Institute is approved by the Indian Organizationot-(such as MCI, DCI, UGC, AICTE, pCL NCERT, NCTEetc.)

(v) This College/Institute is affiliated with(University / Board / Other organization).

(O Copy ofFee Structure as approved & notified by Competent Authority ofCollege/Institute is enclosed.

* Signature of Authorized person ofInstitutior/College

Name (in block letter)Designation:

File No.

Place:

Sr.

No.

Particulars of all nonrefu ndable compulsory fees

payable by the applicant

Amount actually paid by the applicant to th-institution (amount in Rupee)

Remarks,if any

Particulars I Term II Term TotalI Tuition Fees

2. Examination Fees

3. Games

4. Library

5. Medical

6. Identity Card

7. Practical fees

8. Enrolment Fee

9. Laboratory Fee

10. Subject wise extra fee, ifanysuch as Home Science,Geography etc.

ll Any other fees compulsorypayable (to be mentioned itemwise with amount)

TOTALAMOUNT

(Seal of the College/Institute)