Government of Karnataka

DIRECTORATE OF MINORITIES
20 Floor, V.V.Towers, Dr. B.R. Ambedkar Veedhi, Bangalore 560001.
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POST-MATRIC SCHOLARSHIP 2011-12 (FRESH & RENEWAL)

(A Ministry of Minority Affairs - Govt. of India Scheme) For Students belonging to the Minority Communities - Muslims, Christians, Sikhs & Buddhists.
Applications are invited from the students belonging to the minority communities pursuing Class XI / XII (PUC), Vocational Courses in I.T.I/I.T.C., JOC, Diploma - Technical & Paramedical, D.Ed, D.Pharma, GNM, Graduation - B.A, B.Com, B.Sc, B.B.M, B.C.A, BSW, B.Ed, B.P.Ed, B.LibSc, BTA, etc., Post Graduation - M.A, M.Sc, M.Com, MSW, M.Ed, M.PEd, MTA, PG Diploma, etc., M.Phil, & Ph.D for Post-Matric Scholarship to be awarded by the Ministry of Minority Affairs, Government of India.

Conditions to Apply
1.Students who have scored not less than 50% marks in the previous final examination only are eligible to apply. 2.The annual income of the students parents / guardian from all sources should not exceed Rs.2 lakh.

3. Applications are to be sent only by post/courier to the above office address.

LAST DATE TO SUBMIT FILLED IN APPLICATIONS - 6 AUGUST 2011

FOR OFFICE USE ONLY FRESH or RENEWAL

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% of Marks in Previous Final Exam : _______________ Present Class & Course : ______________ Annual Income : ________________ Enclosed : Income Certificate/Affidavit/Salary Certificate Religion : ____________________ Day Scholar ( ) Hosteller ( ) Total Fee : ______________

Signature of the Principal obtained Yes / No.

All required documents enclosed Yes/No

Eligible/Not Eligible (With reasons) : _________________________________________________________ Scrutinized by : _____________________ Date : __________________ Verified by : ________________
PART 1 (TO BE FILLED BY THE CANDIDATE) 1. Full Name (in Block Letters as per SSLC Marks Card)
Affix a self attested recent color passport size photograph (do not staple)

2. SSLC Marks Card Register No. 3. Gender : Male ( Date of Birth Place of Birth ) Female ( ) Religion Domiscile Karnataka ( )

Non Karnataka (

4. Details of Parents/Guardian ( in Block letters) Fathers Name Guardians Name Fathers/Guardians Occupation Annual Income of Parents /Guardian
(Please attach income proof document. See Para 16 for details)

Contact Mobile Number 5. RENEWAL DETAILS

Did you receive the Post-Matric Scholarship by Directorate of Minorities during the year 2010-11 Yes ( ) No ( ) ?

If yes, Amount Received : ________________ Cheque No. _____________

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6. College/Institute Address in full (Don't use Abbreviations)

College Name & Address

PINCODE TALUK

PHONE No. DISTRICT

Name of the Previous Examination Passed

Year

Total Marks

Marks Obtained

% of Marks

7. ACADEMIC DETAILS (i) Current Class Studying (ii) Total Annual Fee
(Kindly attach a xerox copy of Fee receipt issued by the College/Institution)

: _____________________________________________________ (a) Admission Fee : _________ (b) Tuition Fee : _________ Total Fee (a) + (b) : ___________________________________ : _____________________________________________________ : _____________________________________________________

(iii) Course for which the scholarship is sought (iv) Academic Year

8. Details of Educational Qualifications from 10th/SSLC onwards (Please enclose copies of marks cards of 10th / SSLC, PUC, Diploma, ITI, Degree, etc.attested by the principal or self attested)

Examinations Passed

University / Board / Institute / Council of Examination

Year of Passing

Total Marks Obtained from all the subjects (Gross Marks)

Percentage of Marks

9. DAY SCHOLAR OR HOSTELLER (i) Are you staying in a Hostel / Paying Guest / Rented Room for education: Yes ( ) No ( )

(ii) If Hosteller / Paying Guest / Rented Room for education, please furnish the Address below:

______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________

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10. HOME ADDRESS ( IN CAPITAL LETTERS )

Home Address
PINCODE DISTRICT PHONE No. MOBILE No.

11. Bank Details and Account Number of the Student: (Compulsory for Renewal cases/Optional for Fresh Applicants) (i) Name of the student (as in the Bank Account) : _______________________________________________________ (ii) Saving's Account Number : __________________________________________________________________________ (iii) Bank Name : _______________________________________________________________________________________ (iv) Branch Name with Full Address : ____________________________________________________________________ ________________________________________________________________________________________________________ 12. Documents to be enclosed (attached) with the application: (i) Self-attested passport size photograph with signature. (On the first page of the application)

or Attestation by the Principal of college/institute. (iii) Xerox copy of Caste & Income certificate issued by Tahsildar (attested by Gazetted Officer) or (iv) Affidavit on non-judicial stamp paper of Rs.20/- in case of Non availability of income certificate or
(ii) Xerox copies of all Marks Cards with Self Attestation (v) Income certificate from the employer for employed parents/guardian. (vi) Xerox copy of the Fee Receipt with details of Admission & Tuition fee issued by the college/institution. 13. Declaration: (i) I hereby declare that the information given above is correct. I am not availing any other scholarship for this purpose from any other source. I shall abide by the terms and conditions for sanction of the Post-Matric Scholarship. I undertake that if, at any stage, it is found to the satisfaction of the sanctioning authority in the concerned State Government administration that the information given by me is false or if I violate the terms and conditions of the scholarship, the scholarship sanctioned to me, may be cancelled and the entire amount of scholarship will be refunded by me or recovered from me, apart from such penal action as warranted by law.

Signature/Thumb impression of student's parents/guardian

Signature of the student

14. Verification/information to be furnished by the Head of College/Institution: (i) It is certified that the information filled in the above mentioned columns by Shri/Kumari ______________ ____________________________________________________ son/daughter of Shri /Smt ________________________ ____________________________ who is studying in __________course _________ Semester __________ Year for the academic year 2011-12 in our college. He/she is a hosteller ( ) / day scholar ( ) of the college Or

He/She is staying as Paying guest/in a rented accommodation at the address given at para12 as per office records.( Date Place )

: ____________________ : ____________________ Signature of the Principal / Head of the college/institution With official seal having the complete address.

Post Matric Scholarship 2011-12

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IMPORTANT NOTE 1. If you have the Caste & Income certificate issued by Tahsildar, you can attach a Xerox copy of it attested by a gazetted officer along with the application form. 2. If you do not have the Caste & Income certificate issued by Tahsildar , then type the matter given below on a non-judicial stamp paper of Rs.20/- and get it attested by a Public Notary and attach the original to this application. 3. DO NOT attach any ORIGINAL Marks Card or Fee Receipts or Address Proof documents with This application.

AFFIDAVIT FORMAT
(To be typed on a Non-Judicial Stamp Paper of Rs.20/- and notarized by Public Notary with Seal & Signature )

DECLARATION OF PARENTS'/GUARDIAN'S ANNUAL INCOME & MINORITY COMMUNITY

I ....................(Father/Mother/Guardian) Of .................................(Name of Student) who is studying in ................. Standard hereby declare that my annual income from all sources is Rs....... (in figures) Rupees.........only. I declare that I belong to .............. (Muslim/Christian/ Sikh/Buddhist) community. If any stage, it is found that the information given by me is false/not true, all benefits given to the student under the scheme of PostMatric scholarship for students belonging to Minority Communities could be withdrawn and legal action as deemed fit, may be taken against me or my Ward.

Date : _______________ Place : _______________ Address : __________________________________________ __________________________________________ __________________________________________

Signature (Father/Mother/Guardian)

Post Matric Scholarship 2011-12

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