SCHEME OF THE POST MATRIC SCHOLARSHIP FOR

STUDENTS BELONGING TO THE MINORITY COMMUNITY

APPLICATION FORM
FRESH
FOR OFFICIAL USE ONLY
Sl. No of Application

Year

Course

Whether Approved

Please
Paste
Pasport Size
Photograph
APP11320111200000065

Application Number

Full Name

Ansari

Father's Name

ShakilAhmad

Mother's Name

ZaheedaBano

Is State Of Domicile Maharashtra

Application Date

21-08-2011

SameerAhmad

ShakilAhmad

Yes

Corrospondance Address

Address : H.NO. 2120 B WING R. NO 102

STAR COMPLEX NEAR ANAD TALKIES GAIBI NAGAR
BHIWANDI ,

Permanent Address

Address : H.NO. 2120 B WING R. NO 102

STAR COMPLEX NEAR ANAD TALKIES GAIBI NAGAR
BHIWANDI ,

Parent Correspondance Address

N.A

Birth Date

12-09-1994

Gender

Male

Nationality

Indian

Religion

Muslim

Details of educational qualifications from matriculation / SSLC / SSC onwards

Exam Passed

University / Board

Main Subjects

SSC

MUMBAI

MATHS SCIENCE
ENGLISH URDU

FYJC

SCHOOL BOARD

Passing Year

Percentage

2010

65.82

2011

58.00

MATHS PHYSICS
CHEMISTRY
Details Of Course for which scholarship is being sought

Academic Year
Last Course Attended

2011-2012
FYJC

Division / Class / Grade

Last Course Academic Year

2011

Marks Obtained

406

Last Exam Percentage

58.00
XII Science

Course

700

Maximum Marks

Course Duration (In months)

12

Year of the Course

Details Of School / College / Institute

Salahuddin Ayyubi Memorial Urdu Junior College

Name of the School/College/Institute

where admitted

Address : Maulan Azad Road Shanti Nagar ,

Nearby Location : Shanti Nagar ,
City : Bhiwandi
District : Thane
PinCode : 421302

Address
For Renewal Scholarship

i)

Previous year sanction order No.

ii)

Serial no.in sanction list.

Name of examination passed

Year

Maximum
Marks

Marks
Obtained

Applied Fee Details

Serial No.

Fee Type

Fee Amount

Admission Fee

600

Tution Fee

7200

Library Fee

Examination Fee

Other than refundable deposits

1200

Day Scholar or Hosteller

Benificiary Category

Day Scholar

Name Of the Landlord

N.A

Rent per Month

N.A

Full Postal Address

N.A

Pin Code

N.A

Telephone No of the Landlord

N.A

Mobile No of the Landlord

N.A

Details Of Bank Account

Name of the payee (as in bank accounts)

SameerAhmad Ansari

% of Marks

Bank Account Number

Type of Bank Account

Name of the Bank

STATE BANK OF INDIA

Branch Name

MALSHIRAS
Address : DIST SOLAPURSTATE MAHARASHTRA ,

Branch Address
Branch Contact

Telephone No : N.A Mobile No : N.A

MICR Code

413002369

IFSC Code

SBIN0011516

Annual Income of Parents/Guardian of student

TotalAnnualIncome in Rs

40000

In words in Rs

Fourty Thousand

Documents enclosed with the application

Documents

Anexure -I Declaration Of Family Income and Minority Status

Declaration

(i) I hereby declare that all the information given above is correct.
(ii) I am not availing any other scholarship for this purpose from any other source.
(iii) I shall abide by the terms and conditions of the Post-matric scholarship.
(iv) I undertake thatif,at any stage,it is found to the satisfaction of the sanctioning authority in the
concerned State govt/Union Territory Administration 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 the scholarship will be refunded by me or recovered from me,apart
from such penal action as warranted by the law.
Date
Place

8/21/2011

Signature of the Student

Part - II
(to be filled by the Head fo the School / College / Institute)
22.

Details of School/ College/ Institute including residential ones :

i)

Name of ths School / College / Institute where admitted:

.............................................................................

ii)

Address of School / College / Institute

.............................................................................
.............................................................................
.............................................................................

iii)

Telephone No.

.............................................................................

iv) Fax No.

.............................................................................

v)

.............................................................................

.............................................................................

e-mail Address

vi) if a private institute,

is the School/College/Institute recognized?
If so,the name of authority which has recognized it

23.

i)

Verification / Information to be furnished by the Head of School/ College / Institute :

It is certified that the information filled in the above mentioned columns by

Shri /Ku

......................................................................................................................................................

S/o / D/o Shri

who is admitted in

..............................................................................................................................................
........................................

course,for the academic session

.....................................................................................
ii)

.......................

School/ College / Institute is correct.

He / She is a Hosteller / Day scholar of the school/College / Institute

OR

He / She is staying as paying guest in a rented accommodation at the address given in Sr.No.17 as
per office record.
iii)

He / She is a fresher admitted in the school for the academic year

...................................

OR

He / She has been promotted from

Year ...............................

.......................

to

......................

in the academic

in

24.

Details of bank account of school/college /institute

i)

Name of the payee (as in the bank accounts)

: .............................................................................

ii)

Name of the Bank

: ............................................................................

iii)

Bank Branch (full address)

: ............................................................................
............................................................................
............................................................................
State :

............................................................

District :

............................................................

Pin :

............................................................

iv)

Branch Code Number

: ............................................................................

v)

Bank Account Number

: ............................................................................

(Inwords.........................................................................................................................................)
vi)

Type of Bank Account Saving / Current.

: ............................................................................

vii)

M.I.C.R Code of the Bank

: ............................................................................

viii)

Model of Electronic transfer available in the Bank.

ECA / RTGS / NEFT / CBS Code number (if any).

25.

For Renewal of Scholarship:

It is certified that the above mentioned student has passed the

examination for

.................................(year

and has obtained

...................................................................
......................% of marks.

It is also certified that the student has not changed the course of study and/or the School/College/
Institute of the study for which the scholarship was originally awarded/has changed the course of study
and/ or school /college /institute with prior approval of the State Government (Please strike out which is
not applicable.

Date :

.............................

Place

..............................

Signature of Head
of the school/college/institute
with official seal

Annexture - I

DECLARATION OF FAMILY INCOME AND MINORITY STATUS

...........................................................................................................................................................

(Father/Mother/Guardian) of

...........................................................................................................................

(Name of the student) who is Studying in

.........................................................................................................

hereby declare that my annual income from all sources in Rs ..............................................................................

in word Rs

.....................................................................................................................................................

I also declare that I belong to

.........................................................

minority community declared as

Minority Community by Government of Maharashtra, General Administrative Department Notification

No. RAA/2005/89/CR 19/2005, dated 9th November, 2006.
If at any stage, it is found that the information given by me is false, all benefits given to the student under the
scheme of

will be withdrawn

"Post Matric Scholarship to the students belonging to Minority Communities"

and legal action as deemed fit, may be taken against me or my ward.

Affix
revenue
stamp
Signature

Signature

Student

Date :

(Father/Mother/Guardian)

Residential Address:-

At post

Tq

Dist.