3/2/2017 NationalHandicappedFinanceandDevelopmentCorporation

Applicaon/RegistraonNo.(TF/13/04457)

SCHOLARSHIPSCHEMEIIFOR2500DIFFERENTLYABLEDSTUDENTS
(TobefundedoutofTrustFundforEmpowermentofPersonswithDisabilies)
PARTA
(Tobelledupbycandidate)Applicaonforconnuaon/renewalofawardofscholarship

1. NameoftheCandidate : GAURAVJAISWAL
2. Father'sName : ANAND
3. NameoftheState : BIHAR
4. MobileNo. : +91~9801430551
5. ResidenalAddress : V.P.OPAKHANAHABAZAR,VIABETTIAH.
DISTWESTCHAMPARAN,BIHAR
District:WESTCHAMPARAN
State:BIHAR
Pin:845438
6. InstuonalName&Address : DIRECTORSARDARVALLBHBHAINATIONAL
INSTITUTEOFTECHNOLOGY,SURAT
Address:ICHCHHANATH,SURAT7
District:SURAT
State:GUJARAT
Pin:395007
7. Sex : M
8. EducaonalQualicaon : XII
9. NameoftheBoard/University : CENTRALBOARDOFSECONDARY
EDUCATION
10. CourseinwhichStudying(current) : B.TECH(CHEMICALENGINEERING)
11. DuraonofCourse : 4Yrs.
12. TypeofDisability : OH(OrthopaedicallyHandicapped)
13. PercentageofDisability : 50%
14. StudentBankDetail
BankName : STATEBANKOFINDIA
BankBranchName : SBI,SVRCETBRANCH
BankAddress : SVNITCAMPUS,ICHHANATH,SURAT
BankAccountNo. : 33341569269
IFSCCodeNo. : SBIN0003320
15. Academicrecords(AachcopyofCercateandMarks : PageNo..............
SheetsMatric&above)
16. FamilyIncomeCercate/ProofofAnnualIncome
(Criteria<=Rs.300000p.a)e.g.salaryslip,lastincome : PageNo..............
taxassessmentorder
17. AestedcopyofDisabilityCercate : PageNo..............
18. CourseFeereceipt(ifany)withbreakupofeachItem : PageNo..............
dulypaidduringtheCurrentacademicsession

*(PhotocopiesothedocumentsfromS.No.12to15shouldbeaestedbytheGazeedocer)

Signatureofthecandidate
(ForOcialuse)
(i)Courseinwhichadmied:
(ii)Qualicaonrequiredforthecourse:
(iii)Marksobtained:

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3/2/2017 NationalHandicappedFinanceandDevelopmentCorporation
Applicaon/RegistraonNo.(TF/13/04457)

AnnexureB

SCHOLARSHIPSCHEMEIIFOR2500DIFFERENTLYABLEDSTUDENTS
(TobefundedoutofTrustFundforEmpowermentofPersonswithDisabilies)
PARTB
ApplicaonforConnuaon/RenewalofawardofScholarship

1. Name: GAURAVJAISWAL
(asinSecondary/SeniorSecondarycercate)
2. Address: V.P.OPAKHANAHABAZAR,VIABETTIAH.DISTWEST Pleasepasteyou
CHAMPARAN,BIHAR passportsize
State: BIHAR photointhis
Teleno.(ifany): space.
3. DateofBirth: 14Sep1996
4. MobileNo: +91~9801430551
5. Sexpleasespecify(MMale,FFemale): M
6. (i)Typeofdisability(Pleasespecify): OH(OrthopaedicallyHandicapped)
[(1)OrthopaedicallyHandicapped,(2)HearingHandicapped,(3)BlindnessorLowVision,(4)Otherdisabiliese.g.CerebralPalsy,Mental
RetardaonMulpleDisabilies,ProfoundorSevereHearingHandicapped]
(ii)DisabilityPercentage: 50%
(Pleaseencloseanaestedcopyofthedisabilitycercate)
7. EducaonalQualicaon
Nameofthe
Board/
University/
Examinaon Nameofthe Instuon Max Marks Marks Class/ Serial Passing
MajorSubjects
Passed Instuon OfLast Marks obtained (%) Division No. Year
Educaonal
Qualicaon
Obtained
CENTRAL
JNV,VRINDAVAN.WEST BOARDOF
XII HINDI,ENGLISH,PHYSICS,CHEMISTRY,MATH 307 61.4 PASS
CHAMPARAN SECONDARY
EDUCATION
CENTRAL
JNV,VRINDAVAN,WEST BOARDOF HINDI,ENGLISH,MATH,SCIENCE,SOCIAL
X 79.8 8.4 PASS
CHAMPARAN SECONDARY SCIENCE
EDUCATION
CENTRAL
JNV,VRINDAVAN,WEST BOARDOF FIRST
VIII HINDI,ENG,SST,SCIENCE,MATHS 405 81
CHAMPARAN SECONDARY DIVISION
EDUCATION
Incaseofgrades,pleasemenonequivalent%ofmarksandalsoencloseauthencatedconversionformula
8. FamilyIncomeperannum(inRs.): 80000
PleaseencloseIncomeCercate)
9. (i)Courseinwhichstudying: B.TECH(CHEMICALENGINEERING)
(ii)CurrentAcademicSession: 201617
(iii)Duraon: 4Yrs.
(iv)Yearinwhichstudying: IVTHYear
10.Nameandaddressoftheinstuonwherestudying: DIRECTORSARDARVALLBHBHAINATIONALINSTITUTE
OFTECHNOLOGY,SURAT
Address:ICHCHHANATH,SURAT7
District:SURAT
State:GUJARAT
Pin:395007
11.DetailsofScholarship/Spend/nancialassistancebeing No
receivedforthesamecourse(ifany).
Applicaon/RegistraonNo.(TF/13/04457)
12. IfinreceiptofscholarshipfromtheMinistryofSocial
JusceandEmpowerment,pleaseindicatetheyearand Year Reg.No.
registraonnumberoftheapplicaon
13. Anyotherinformaonapplicantwishestoprovide.

I hereby declare that informaon provided above is true to the best of my knowledge and I am aware that providing wrong
informaonwillmakemeliabletolegalaconandrecoveryofscholarshipamount.

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3/2/2017 NationalHandicappedFinanceandDevelopmentCorporation

Date:
Place: Name&Signatureoftheapplicant

Enclosures:

(i) Aestedcopiesofmarksheetsofallsemestersinwhichappearedinlast/previousacademicyearsmustaestedbyGazeed
Ocer/headoftheinstute.
(ii) Coursefeereceiptifany,dulypaidduringcurrentAcademicSession,dulyceredbytheheadoftheinstuon.
(iii) Bonadecercateofstudentwithphotoissuedbyheadoftheinstuonindicangthatthestudentiscurrentlystudyingin
theinstute.

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3/2/2017 NationalHandicappedFinanceandDevelopmentCorporation
Applicaon/RegistraonNo.(TF/13/04457)

(TOBEFILLEDINBYINSTITUTION)
Recommendaonoftheinstuon
(onlyoneapplicaonperstudentistoberecommended)

1.CerfythatGAURAVJAISWALisstudyingincourseofB.TECH(CHEMICALENGINEERING)whichis
(pleasecktherelevantorspecify)Diploma/Degree/PGlevelstudy/anyother(pleasespecify)andispresentlystudyingin
(Tickwhicheverisapplicable) IYear IIYear IIIYear IVYear
Theduraonofthecourseis 4Yrs.

2.TheinformaonfurnishedabovebythestudentisinorderandcorrectasperrecordsoftheInstuon.

3.ThefamilyincomeasperrecordoftheinstuonsisRs.80000perannum.
4)IntuionalBankAccountDetails
a)BankName:
b)BankBranchName:
c)BankAddress:
d)AccountNo.:
e)IFSCCode:
5.Thestudentisreceivingscholarship/nancialaid/spendforthesamecourse.(Yes/No).No
IfYes,thedetailsthereof:
6.Generalconductofthestudentissasfactory/unsasfactory(pleasestrikeoutwhicheverisnotapplicable)
7.ItisceredthatthisinstuonisrecognisedbyCentralGovt./StateGovt./AICTE/UGC/RCIoraliatedtorecognised
university_______________________________.

Date: Signature&NameofHeadofInstuonRegistrar/Dean
Place: SealoftheInstuon

NaonalHandicappedFinance&DevelopmentCorporaon(NHFDC)
(DepartmentofEmpowermentofPersonswithDisabilies,
MinistryofSocialJusce&Empowerment,Govt.ofIndia)
O:PHDHouse,IIIrdFloor,4/2,SiriInstuonalArea,
AugustKranMarg,NewDelhi110016
Tel:01145803730(Ext214),TeleFax:01145088636

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