ALL INDIA COUNCIL FOR TECHNICAL EDUCATION

(7th Floor, Chandralok Building, Janpath, New Delhi, 110 001)

Application Format
Scholarship for Girls under PRAGATI scheme
and
Scholarship for Differently abled students

FOR OFFICE USE ONLY:

Sr No of Application

Year

Course

Whether Institute is Approved by AICTE (Y/N)

To be filled by the student:

Application for Girls
Scholarship (Yes/No)
Application for differently
abled scholarship
(Yes/No)

1. Full Name (In Block Letter)

Surname
First Name
Middle Name
Fathers Name
Mothers Name
Student unique id 1 2. Address for correspondence
Name
House Number

Paste here a
passport size
photograph self
attest it with part of
the signature on the
photo and the
application form.

Mohalla/Street
City/Town/Village
District
State
Pin Code
Telephone/Mobile
number, if any
e-mail ID, if any
3. Parents Address
Name
House Number
Mohalla/Street
City/Town/Village
District
State
Pin Code
Telephone/Mobile
number, if any
e-mail ID, if any
4.
Permanent Address
Name
House Number
Mohalla / Street
City/Town/Village
District
State
Pin Code
Telephone/Mobile
number, if any
5. Date of Birth
D D M M Y Y Y Y

6. Gender
Male Female

7. Other details
Religion
Nationality

Category(Open /
SC / ST / OBC)
Whether
belonging to
Minority
community (Yes /
no)
Name of Minority
(if applicable)
Whether
differently abled
(PH) (Yes / No)
Category of
disability (if
applicable)
% Disability (if
applicable)
Disability
Certificate issuing
authority (if
applicable)
8. Parents Details (Mother / Father / Guardian (Tick appropriate)
Occupation
Government
service (Yes /No)
Semi Government
service (Yes /No)
Private service
(Yes /No)
Business (Yes
/No)
Agriculture (Yes
/No)
Other (Please
specify)
Post / Designation
(if applicable)
Name of the office
with full address
(in which
employed, if
applicable)
9. Details of educational qualifications from std. Xth onwards

Sr. Examination
No Passed

Std Xth

Std XIIth

University /
Board/
Institution /
Council of
Examination

Year of
Passing

Marks
obtained

Marks
out of

% marks
obtained in
Board /
University

Division /
Class /
Grade

3
10. Details of course in which the student is admitted and scholarship is being sought
1
Name of Course
2
3
4
5
6

Duration of Course
Part Time/Full Time
First Shift / Second Shift
Academic year
Date of admission to first
year course in the current
academic year
Class last attended (Xth /
XIIth / any other )

Academic
Year

11. Details of the Institution to which the student is admitted for the current academic year
1
Permanent id of the
1Institute (PID)
2
Name of the Institute
3

Address of the Institute

4
5
6
7

District
State
Pin Code
Name of the Principal /
Director / Head of the
Institute

12. Total Annual Tution Fee

Sr Item
Annual tuition
No
Fee Paid (Rs)
1
Tuition Fee

Rupees (In words)

Note: Please enter the Tuition Fee details and not the other fee like development /
Library / Laboratory etc.

13. Details of Bank Account of student (Joint account will not be allowed)
Name of the
Student
Name of Bank
Bank Account No
Bank IFSC Code
Bank Branch(full
address)
Branch code
Type of Bank
Account(Saving /
Current)
MICR code of
bank
Student PAN
number (if
available)
Enrollment- id
(AADHAR) (if
available)
AADHAR- id
(UID) (if
available)

14. Annual family Income of Parents of the student:- Rs. in

words..
(Certificate of annual family income is to be given only in the prescribed format enclosed as
Annexure-III along with the application).
15. Documents enclosed with the application ( Attach following attested documents along with
the application)
Sr
Name of the document
Attested
Attached
No
(Yes / No) (Yes/No)
1
Copies of mark sheet of standard Xth / XIIth / Others as
applicable and as filled up in Sr no. 09
2
Copy of annual family income certificate for the financial year
2013-14 in the prescribed format issued by Tahsildar or higher
officer
3
Copy of certificate issued by Competent authority in case of
differently abled candidate (PH candidate) (if applicable)
4
Copy of admission letter to Diploma / Degree course

5
6
7
8
9
10

Copy of Tuition Fee Receipt

Copy of Bank Pass Book showing name of the student, Account
number, IFSC code and Photograph
Copy of student PAN card (if available)
Copy of AADHAR card (if available)
Certificate issued by the Director/ Principal / Head of the
Institute (Annexure-I)
Declaration by Parents (Annexure-II)

16. Declaration by the student

1. I hereby declare that the information given above is correct.
2. I have secured admission in first year Diploma / Degree program during academic
session 2014-15 through centralized admission process conducted by state admission
counseling authority.
3. I am not availing any other Scholarship for this purpose from any other source.
4. I shall abide by the terms and conditions for sanction of the Scholarship.
5. I undertake, that if at any stage, it is found that the information given by me is false or if I
violate the terms and conditions of the Scholarship, the Scholarship sanctioned to me,
will be cancelled and the entire amount of Scholarship will be refunded by me or
recovered from me, apart from liability of penal action as warranted by law.

Signature of the Candidate:

Date:
Place:

Annexure-I
Certificate
(to be issued by Director / Principal / Head of the Institute)

It is certified that the information filled in the application by Shri / Smt / Kumari
...................... s/o, d/o,
Shri.who is admitted in
.Course for the academic session 2014-2015 through centralized
counseling in
..college
having Permanent id (PID) 1-is correct.

Signature:
Name of the Director/Principal/Head of the Institute:

Date:
Place:

Annexure-II

Declaration by Parent
(Please strike off whichever is not applicable)

It is certified that the information filled in the application by my son/daughter Shri / Smt /
Kumari .....who is
admitted in .Course for the academic session 2014-2015 through
centralized counseling in .college is
correct.
I
certify
that
only
one
daughter
of
mine
namedis
making the current application to avail this facility.
Further, I undertake to submit that, I will be availing the facility of scholarship for Girls
under PRAGATI scheme only for my daughter Kum

and

not for any other girl child of my family.

I undertake, that if at any stage, it is found that the information given by me or my
son/daughter is false or if I or my son / daughter violate the terms and conditions of the
Scholarship, the Scholarship sanctioned to my son / daughter, will be cancelled and the entire
amount of Scholarship will be refunded by me or recovered from me, apart from liability of
penal action as warranted by law.

Signature:
Name of the Parent:
Date:
Place:

Annexure-III
Family Income Certificate
This is to certify that Shri/Smt./. ..............is
Mother
/
Father
/
Guardian
of
Shri/Smt./
Kum.
(Candidate). is resident of
Village/Town.District / Division......in
the.. State.
As per the declaration / records, his / her annual family income for the financial year 2013-14
from all the sources is Rs.........(in
words ) ..Only.

Dated:

Seal

Tehsildar/District Magistrate/Deputy Commissioner