ECSS- Educational Crisis Scholarship Support Affix recent color

An initiative of HDFC Bank photo of the student

and sign across the
photograph
Education is the investment our generation makes in the future ~ Mitt Romney

APPLICATION FORM

Put a tick () wherever applicable PLEASE FILL THE ENTIRE FORM IN CAPITAL LETTERS ONLY
1. Personal Details
Where did you learn about the Scholarship? a) ATM b) Social Media c) School/ College d) Friend/ family
/ Hospital/ NGO
e) HDFC Bank Branch f) Other (specify) _________________________________________
Student Category a) School b) College c) University
Name of the student

Gender a) Female b) Male

Date of Birth
D D M M Y Y Y Y

Current Class / Year

Specialization (if any)

% Marks obtained in the last class %

Father's / Guardian's Name

Mother's Name

Relationship with guardian

2. Contact Details

Residential Address
(please write the complete postal address)

Landmark

City/District

State

Pin Code

Phone Number Landline (with STD)

Phone Number(Mobile)

E-mail (if any)

1
3. Family Details

Name of the member Relation with the child Age Education Occupation Annual Income

Total Annual Income

No. of dependent members (No. of non earning members)

Type of family a) Nuclear/ Single b) Joint

4A. Socio-Economic Details

Destitute of family / orphan a) Yes b) No If yes, specify year of death

Single parent child / a) Yes b) No

If yes, specify year of separation/ death
divorced parents

Differently abled child a) Yes b) No If yes, specify

If yes, specify name of disease/illness

Parents/child/siblings suffering/ a) Yes b) No
under treatment for life Year of detection
threatening illness
Undergoing treatment at

Crisis such as disaster/ a) Yes b) No

If yes, specify year of occurrance
accident/ loss of job, etc

4B. Total Annual Income of Family from all sources is

Less than Rs. 50000

Between Rs.50000 to Rs.1.5 lakhs

Between Rs.1.5 lakhs to Rs.2 lakhs

Between Rs.2 lakhs to Rs.3 lakhs

Rs. 3 lakhs & above Specify

4C. Nature of Dwelling / House

Own

Rent

2
5. Institute Details

Name of the School/College/University

Type of School/College/University a) Private b) Government c) Government aided

Curriculum (in case of school) a) CBSE b) ICSE c) State Board d) IB/CIE e) Other

Recognized by

Annual School/College/University Fee

Complete address of School/

College/University

Landmark

City/District

State

Pin Code

Phone Number (with STD Code)

Email ID

6. Previous Scholarship

Have you applied for ECSS before a) Yes b) No

If so, which year

Have you received the ECSS Scholarship before a) Yes b) No

If so, which year

Is any other sibling (own brother/sister) applying for the Scholarship ? a) Yes b) No

If Yes, Name of the sibling (own brother/sister)

7. Briefly describe the reason of applying & impact of scholarship on the child's education
(Kindly mention the crisis and cause of emergency clearly and explicitly)

8. Please provide two references (Referees can be School Principal, Doctor, Teacher, NGO, etc. but nor friends or relatives)

Sr. Tel. No (with STD Code) Relationship

Name of the person Occupation E-mail id (if any)
No. / Mobile No. with applicant

3
 9. Nearest HDFC Bank Branch

Name of nearest HDFC Bank Branch ____________________________________________________________________________

Branch Code _______________________________

10. Branch Verification

*Required only for manual submission
Ensure that the following documents are securely a ached and put a ck () wherever applicable

Students last academic years report card

Income proof from employer (Annexure IA). In case of self employment, self attested income declaration. (Annexure IB)

Verification certificate from school/ college/university (Annexure II) duly signed and stamped by school/college/university authority

Any 2 Address Proof (Aadhar-UIAID Card/ ration card/ passport/electricity bill/ phone bill)

Atleast one of the above 2 is government authorised with parents' name

A doctor's note confirming the medical status of the participant or family member in case of illness or disability

10th / 12th marksheet (NA for students of classes VI-X)

Submission: The Branches are requested to send the Applica on Forms at the following address:
Corporate Social Responsibility,
HDFC Bank, Alpha Building, I-Think Techno Campus,
9th Floor, Kanjurmarg-East, Mumbai-400042,
Maharashtra, India

Branch Name:______________________________________________ Branch Code: ____________

Signature of Branch Manager__________________________________

Name of Branch Manager____________________________________

Employee Code____________________________________________

Loca on:__________________________Date:___________________ Stamp of the Branch

Declaration by the Student

I hereby declare that all information provided by me is authentic and true to my knowledge

Name : ______________________________________________________________________

Signature :_____________________________________

Date : ____________________________________