STUDENT APPLICATION

Renewal

(MINORITY WELFARE SCHOLARSHIP SYSTEM)

For official use only

Sl No of application

Temporary ID :

T2014RupM01739

Permanent ID :

P2013upM01851

Admission No :

4140906

Year

Course

Whether approved

Affix a self
attested passport
size photograph

1.Student name

ABDUL MAZ

2.Father's name/Husband's name

AKBAR ALI

3.Mother's name

KHATOON BANO

4. Domicile State/UT (State/UT which the

student belongs to)
:

Uttar Pradesh

5. Address for correspondence:

House No. & Street Detail

ROOM NO 12, H.M. HOSTEL, SULAIMAN HALL,

City/Town/ Village & P.O.

A.M.U. ALIGARH

District

ALIGARH

State

Uttar Pradesh

Pincode

202002

6. Permanent address(please enclose residential certificate from concerned state

government authority):
House No. & Street Detail MOHALLA ROUZADARWAZA KHAIRABAD
City/Town/ Village & P.O.
District

SITAPUR

State

Uttar Pradesh

Pincode

261131

7. Date of birth (Please enclose certificate) :

01-Aug-1994

8. Whether male or female

Male

9. Religion

Muslim

10. Nationality

Indian

11. Adhaar No.

NOTE: Scan each page of this application as separate PDF Files for upload after Signing from Institute.
Page 1 of 5
Printed Date: 18-Sep-14

12. Last Examination Passed Details:

Name of examination passed
B.Tech.( Computer Science and Eng.

Year

Marks Obtained

Full marks

% of marks

8.6

10

86.0000

13. Total Annual course fee: 34100.00

(Break up of course fee such as tuition fee, library fee, examination fee etc. other than refundable
deposits):
Sl.No.

Item

Annual fee

1.

Tuition Fee

1100.00

2.

Library Fee

1000.00

3.

Examination Fee

2000.00

4.

Other Non Refundable Fee

30000.00

Total

34100.00

14. Details of bank account of student:

Name of the payee (as in the bank accounts)

ABDUL MAZ

Name of the Bank

STATE BANK OF INDIA

Full address

AMU ALIGARH

Branch Code number

Bank Account Number

33277351288

Bank Account Number in words

IFSC code of the Bank

SBIN0005555

Mode of Electronic transfer available in the Bank

ECS/RTGS/NEFT/CBS/code number (if any);15. Annual Income of parent/guardian of the student: Rs. 48000
(specimen form of declaration of annual income is given at Annexure which is to be signed by the
parent/guardian of the student and enclosed alongwith the application. In case parent/guardian are
employed, income certificate from the employer may also be enclosed)

NOTE: Scan each page of this application as separate PDF Files for upload after Signing from Institute.
Page 2 of 5
Printed Date: 18-Sep-14

INSTITUTION VERIFICATION FORM

Verification/information to be furnished by the Head of institution/college:
It is certified that the information provided below by ABDUL MAZ who is admitted in B.Tech. Computer Science and
Eng. course for the for the academic session 2014-2015 in ALIGARH MUSLIM UNIVERSITY college is correct. He/she
is a hosteler/day scholar of the college.

Details provided in existing print out of form.(last year marks details) .

Details provided in existing print out of form. (Fee details current year).

In case the information filled in these columns is not correct, then the institute should indicate that
separately.

For Renewal of Scholarship:

It is certified that the student has not changed the course of study and/or the institution of the study
for which the scholarship was originally awarded /has changed the course of study and/or institution
with prior approval of the state government (Please strike out
Please ensure the information given by you is factually correct. In case of any discrepancy noticed
later, your application is likely to be rejected.
Date :
Place :

Signature of the head of the

with Official seal

NOTE :

The verification by institution is mandatory for consideration of the application.

NOTE: Scan each page of this application as separate PDF Files for upload after Signing from Institute.
Page 3 of 5
Printed Date: 18-Sep-14

DECLARATION OF FAMILY INCOME

I AKBAR ALI (Father /Mother /Guardian) of ABDUL MAZ (Name of

student) who is studying in B.Tech.( Computer Science and Eng. ) II year hereby
declare that my annual income from all sources is Rs./ 48000.00 if at any stage,it
is found that the information given by me is false/not true,all benefits given to the
student under the scehme of Merit cum means based scholarship to the student
belonging to minority communities could be with dran and legal action as deemed
fit, may be taken against me or my ward.

Signature

Residential Address
Date:
(Father/Mother/Guardian)

MOHALLA ROUZADARWAZA KHAIRABAD

SITAPUR
Uttar Pradesh
261131

NOTE: Scan each page of this application as separate PDF Files for upload after Signing from Institute.
Page 4 of 5
Printed Date: 18-Sep-14

Declaration of the Student

(i) I hereby declare that the information given in my application form (From 1 15) is correct.
(ii) I am not availing any other Scholarship for this purpose from Central Govt./State Govt.
sources.
(iii) I shall abide by the terms and conditions for sanction of the Merit cum Means based
Scholarship.
(iv) I have uploaded the desired documents in support of my claim.
(v) I undertake, that if at any stage, it is found to the satisfaction of the sanctioning authority in
the Ministry of Minority Affairs 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.

Date :

Signature of the candidate

NOTE: Scan each page of this application as separate PDF Files for upload after Signing from Institute.
Page 5 of 5
Printed Date: 18-Sep-14