Dr Avdhoot Shivanand Scholarship

STUDENT INFORMATION FORM FOR SCHOLARSHIP

*Please check application form carefully before filling.

**You will be required to upload Marksheets copy of 10,11,12th class, college admission proof and address proof.

Personal Information

*Please upload details of at least one guardian

Guardian 1

Father’s Name

Guardian 2

Mother’s Name

Student Details

Name of the Candidate*(As per Class XII Certificate)

Date of Birth*

Gender*

Female
Male

Details of Father / Mother / Guardian as the case may be

Name*

Relation*

Permanent Home Address*

State*

City*

Pin*

Profession / Designation*

Office Address*

Details for Communication

Same as permanent address

Address for Correspondence*

State*

City*

Pin*

Phone No.

Mobile No.*

Email ID*

Whether father/guardian is a citizen of India.: (If no then please mention country of citizenship)*

Total annual income of both parents/guardian (in Lakhs ₹)*

Educational Information

Particulars of School/Institution last attended class XII

Name of School/Institution*

Date of entry*

Date of leaving*

Remark, if any

Is the candidate in receipt of any other scholarship from state government or other institution or person*

(If Yes, particulars should be given including the monthly rate and date from which the scholarship is being drawn.)

Details of Class 10th, 11th and 12th Examinations

10th Board*	Institution/University from which passed*	Year of passing*	Percentage of marks obtained*	Class/Grade obtained*

11th Board*	Institution/University from which passed*	Year of passing*	Percentage of marks obtained*	Class/Grade obtained*

12th Board*	Institution/University from which passed*	Year of passing*	Percentage of marks obtained*	Class/Grade obtained*

Certified that the statement made by me in this form is correct. I declare that in case I am selected for a scholarship :

I shall devote my full time to the course of study, and that *
This field is required.
I shall not receive another stipend/ scholarship from any other source*
This field is required.

Place*

Date*

Scholarship Information

Particulars of the course for which assistance is required*

Name Of The Institution*

Name Of The Course*

Duration Of Course( In Years)*

Date Of Commencement*

Likely Date Of Completion*

Annual Course Fee ( Please write the annual Fees of your Course) *

Percentage amount of Scholarship required (Please mention how much % amount of Course Fees is required for scholarship e.g full fees or 50% , etc )*

* We declare that the scholarship sanctioned will be utilised for the students education expenses only.

Please write in 100 words why do you deserve the scholarship ?* You have words remaining

Documents

Guardian Details

Father’s Signature

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Father’s Photo

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Mother’s Signature

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Mother’s Photo

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Student Details

Student’s Signature

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Student’s Photo

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