Application for Continuation/Renewal of award of National Scholarship for Persons with Disabilities
(All information should be given either in English or in Hindi only)

place to affix photograph
  1. Name ________________________________________________________

  2. Address _______________________________________________________

    ________________________________________________________

    ______________State__________________Pin__________________

  3. Date of Birth _____________

  4. Sex (M-Male,F-Female)

    1. Type of disability (Please enclose disability certificate)
      (OH-Orthopadically Handicapped, HH - Hearing Handicapped, VH-Visually Handicapped, C4-Other disabilities e.g. Cerebral Palsy, Low vision, Mental Retardation etc.)

    2. Percentage of disability ___________ %

  6. Educational Qualification

    Examination Passed Name of the Institution Name of the board/University Major Subject Aggregate Marks obtained & % thereof*- Class/Division
    Matric/Secondary          
    Sr.Secondary/Intermediate          
    Graduation          
    Others          
    * In case of grades, mentioned equivalent % of marks and also enclose conversion formula

  7. Family income per annum (in Rs.)_______________ (enclose Income Certificate)

  8. (i) Course applied for (complete name)_______________________________

    (ii) Academic Session ____________________ (iii) ___________________

    (iv) Date of Admission ___________________

  9. Name and address of the institution where course will be under - taken.

    _________________________________________________________________

    _________________________________________________________________

    _________________________________________________________________

  10. Whether hosteller or a day scholar (If hosteller please specify whether provided by the institution or own arrangement and address of the hostel) _______________________________________________________________

    __________________________________(Enclose Certificate)

  11. Details of scholarship/Stipend/financial assistance being received for the same course (if any)
  12. Any other information applicant wishes to provide.
I hereby declare that information provided above is true to my knowledge and I am aware that providing wrong information will make me liable to legal action and recovery of scholarship amount.

Name & Signature of the applicant

Date:

Place:

Recommendation of the Institution

TO BE FILED BY INSTITUTE
  1. Certified that Sh./Ms. _____________________________ is studying course of professional course and is presently studying in the following year of the course (Tick whichever is applicable):


    The duration of the course is --------------------------
  2. The information furnished above by the student is in order and correct as per records of the institution.
  3. The student is receiving scholarship/financial aid/stipend from__________________/not receiving any scholarship/financial aid/stipend from any other source as per records of the institute.
  4. General conduct of the student is satisfactory/unsatisfactory
(please strike out whichever is not applicable)

Signature & Name of Head of
Institution/Registrar/Dean

Date: ________

Place: ________

Seal of the Institution

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