MERCK INDIA CHARITABLE TRUST

Scholarships for Academic Excellence

A, Shivsagar Estate, Dr. A.B. Road, Worli, Mumbai 400 018
Tel: 66609000, 6660 9141 Fax: 24930507, Email: charitable.trust@merck.co.in
APPLICATION FORM

Forms can be downloaded from www.merck.co.in or can be collected from Merck Limited office.
Applications are invited from the students scoring above 80% in SSC examinations.
The application forms duly filled should be submitted to Merck Limited office within 10 days after the
declaration of the SSC Board Exam results.
Attach certified copy of your SSC examination mark sheet and a passport size photograph with the
application form.
Application form must be signed by the applying student and the parent / guardian of the applying student.
Incompletely filled and those without the required supporting documents will not be considered.
Only selected students will be informed by email or telephone for the first round of Interview.
The decision of the Board of Trustees is final and no disputes would be entertained.
FILL IN CAPITAL LETTERS
PERSONAL DETAILS

Name: Mr./ Ms. __________________________________________________________________________

(First Name)
Date of Birth: ____ / _____ / _____
(DD)

(MM)

(Middle Name)

(Last Name)

Place of Birth :_____________________________________

(YY)

Parent /Guardian Name ____________________________________________________________________

Service / Profession:

_____________________________________________________________________

Present Address

_____________________________________________________________________
_____________________________________________________________________

Permanent Address:

_____________________________________________________________________
_____________________________________________________________________

Contact Details:

Tele No. (R)______________________

(Mobile) __________________________

E-mail ID ____________________________________________________________
EDUCATION DETAILS

Examination
Passed

CLASS X
CLASS IX
CLASS VIII

Name & Address of the School / Div.

Board / University

Month & Year

of Passing

Marks
Obtained /Out
of Total Marks

Percentage of
Marks (%)

MERCK INDIA CHARITABLE TRUST

Scholarships for Academic Excellence
A, Shivsagar Estate, Dr. A.B. Road, Worli, Mumbai 400 018
Tel: 66609000, 6660 9141 Fax: 24930507, Email: charitable.trust@merck.co.in

Specify any academic / merit achievements or awards that you have received in the past
________________________________________________________________________________________
Mention your reasons for choosing the above field of study and how do you think it will benefit you?
________________________________________________________________________________________
Specify the educational course that you would like to pursue henceforth
________________________________________________________________________________________
Explain briefly your carrier plans
________________________________________________________________________________________
Which are the educational institution(s) you wish to apply?
________________________________________________________________________________________
Write in brief about your extra-curricular activities & interests
________________________________________________________________________________________
FINANCIAL DETAILS

Total number of earning members in your family ________________________________________________

Total Family Income p.m.
Below 5000 p.m.

5000 - 10000 p.m.

10000 - 15000 p.m.

Above 15000

Details of your current source of financial support

_______________________________________________________________________________________
State your reason for seeking extra financial aid

_______________________________________________________________________________
Declaration by the Applicant and Parent/Guardian
I declare that the information given by me in this application for obtaining scholarship is true to the best of my
knowledge and that I have not withheld any relevant particulars. I have disclosed all the information correctly
as required to be given in this application. If any information provided is wrong or misleading, the scholarship
is understood as seized immediately.
Signature of Applicant

_______________________

Date _______________

Signature of Parent / Guardian ______________________

Date _________________