Application form for SC/ST (Central Sector Scholarship Scheme under Top Class Education)

(FRESH/RENEWAL)(tick as applicable)

1.Name of the Applicant (in BLOCK LETTERS):

2.Category (SC/ST):

3.Department:

(i)Institute Roll No:

(ii)Hostel Name and Room No.:

(iii)E Mail :

(iv)Mobile No.:

4.AIEEE/JEE Rank:

5.AIEEE/JEE Roll No.:

6.Name of bank account holder:

(The account in which scholarship is to be transferred)

7.Bank and Branch address:

8.Bank Account no. :

9.IFSC Code:

10.Father’s Name(IN BLOCK LETTERS) :

11.Mother’s Name:

12.Guardian Name (if any) and Relationship:

(i)E Mail :

(ii)Mobile No.:

(iii)Reasons for being under Guardianship, if other than father/mother:

13.Present Postal address of guardian:

14.Annual Income of parents through all sources:

15.Parents Occupational Status (tick as applicable)

(i)In service (Government/ Private/ Public)

(Supported by IT form 16/ Saral Form whose annual income is above Rs. 50000/-)

(ii)Other than Salaried/ Pensioner

(supported by Annual Income Certificate to be issued by SDO/BDO/MRO/Tahasilder/Local Municipal Corporation/ Gram Panchayet, etc)

(iii)If business/ Medical/ Legal Practitioner/ Consultant etc

a)Name and Address of Firm/ Organization/ Shop

b)Nature of Business/ Trade

c)Trade/ Professional License / Registration No. (Copy to be enclosed)

d)Sales Tax/ Commercial Tax Registration No/ Zone

(iv)Pensioners/ Family Pensioners

(Supported by Non Employment certificate to be issued by SDO/BDO/MRO/ Tahasilder/ Local Municipal Corporation Gram Panchayetetc

16.Details of students alongwith fund requirement under the scheme of top class education for ST students:

Name of
student / Father’s
name / Complete address / ST
Community to
which
candidate
belongs / State to
which
the ST
student
belongs / Inter se
seniority
among
ST
students
admitted
on merit / Course of
study
along with
duration of
the course / Semester
/Year of
study / Annual
family
income / Annual
Tuition
fee / Other non refundable
charges / Living
expenses
(Actual
subject to
maximum
ofRs.
2200/-
p.m.) / Cost of
Books &
Stationery
(Actual
subject to
maximum of
Rs. 3000/-
p.a.) / Cost of
Computer
@
Rs.45000/-
/actual
(one time
grant) / Total
(10+11+12+13
+14)
1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10 / 11 / 12 / 13 / 14 / 15

17.Details of students alongwith fund requirement under the scheme of top class education for SC students:

Name of the students / Father’s Name / Complete Address / Annual total family income / Name of the entrance exam and rank no. / Inter-se ranking in the institute / Course of study in which admission secured / Duration/ length of the Course / Year ('n' th) in which presently studying / Annual Fee / Other non-refundable charges / Lodging & boarding charges
(Actual
subject to
maximum
ofRs.
2200/-
p.m.) / Books & stationery
(Actual
subject to
maximum of
Rs. 3000/-
p.a.) / P-IV Computer, UPS, Printer,Multi-media
@
Rs.45000/-
/actual
(one time
grant) / Total (10+11+12+13
+14)
1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10 / 11 / 12 / 13 / 14 / 15

18.UNDERTAKING

I, ……………………………………………...... ,a student of…………………. year , bearing Institute Roll No. ………………………. of NIT, AP during the session 20…………. , do hereby solemnly declare that I will strictly adhere to the rules and regulation for grant of scholarship and undertake that:

1)I must secure minimum 75% attendance in all the subjects.

2)I am not in receipt of any stipend and scholarship from Institute and other sources.

3)I have been informed that at NIT, AP, no student can receive two scholarships simultaneously.

4)I am not employed in anywhere.

5)No disciplinary action has been taken against me by the Institute in the preceding session 20__-__

6)I shall abide by all the rules, regulations, terms and conditions of the scholarship and maintain discipline in the Institute. I undertake, that if at any stage, it is found to the satisfaction of the sanctioning authority of the respective Ministry, Govt. of India that the information given by me is false

or if I violate the terms and conditions of the Scholarship, the Scholarship sanctioned to me, may be cancelled and the entire amount of scholarship will be refunded by me or recovered from me, apart from liability for such penal action as warranted by law or Institute Authority and Ministry.

Signature of father/ GuardianSignature of Student

List of Enclosures:

1. Caste Certificate

2. Certificate of Annual Family Income duly signed by district revenue officer

3. Copy of JEE Rank card (for fresh proposals)

4. Progress Report (for renewal cases)

5. Inter-se ranking in the institute

6. Inter se seniority among ST students admitted on merit