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APPLICATION FORM
FRESH
FOR OFFICIAL USE ONLY
Sl. No of Application
Year
Course
Whether Approved
Please
Paste
Pasport Size
Photograph
APP11320111200000085
Application Number
Full Name
Shaikh
Father's Name
AbHakim
Mother's Name
Naseem
Application Date
21-08-2011
SkMujahid
AbHakim
Yes
Corrospondance Address
Permanent Address
N.A
Birth Date
24-10-1992
Gender
Male
Nationality
Indian
Religion
Muslim
Exam Passed
University / Board
Main Subjects
SSC
MUMBAI
MATHS SCIENCE
ENGLISH URDU
Passing Year
2011
Percentage
72.00
Academic Year
Last Course Attended
2011-2012
SSC
2011
Marks Obtained
396
72.00
XI Science
Course
550
Maximum Marks
12
Address
For Renewal Scholarship
i)
ii)
Year
Maximum
Marks
Marks
Obtained
Serial No.
Fee Type
Fee Amount
Admission Fee
600
Tution Fee
7200
Library Fee
Examination Fee
1200
Benificiary Category
Day Scholar
N.A
N.A
N.A
Pin Code
N.A
N.A
N.A
SkMujahid Shaikh
% of Marks
25001580187
BANK OF MAHARASHTRA
Branch Name
NARPOLI
Address : DHAMANKAR PLAZA 1ST FLOOR DHAMANKAR NALA BHIWANDI ,
Branch Address
Branch Contact
MICR Code
400014110
IFSC Code
MAHB0000586
TotalAnnualIncome in Rs
86000
In words in Rs
Documents
Declaration
(i) I hereby declare that all the information given above is correct.
(ii) I am not availing any other scholarship for this purpose from any other source.
(iii) I shall abide by the terms and conditions of the Post-matric scholarship.
(iv) I undertake thatif,at any stage,it is found to the satisfaction of the sanctioning authority in the
concerned State govt/Union Territory 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 the scholarship will be refunded by me or recovered from me,apart
from such penal action as warranted by the law.
Date
Place
8/21/2011
Part - II
(to be filled by the Head fo the School / College / Institute)
22.
i)
.............................................................................
ii)
.............................................................................
.............................................................................
.............................................................................
iii)
Telephone No.
.............................................................................
.............................................................................
v)
.............................................................................
.............................................................................
e-mail Address
23.
i)
......................................................................................................................................................
..............................................................................................................................................
........................................
.....................................................................................
ii)
.......................
He / She is staying as paying guest in a rented accommodation at the address given in Sr.No.17 as
per office record.
iii)
...................................
OR
.......................
to
......................
in the academic
in
24.
i)
: .............................................................................
ii)
: ............................................................................
iii)
: ............................................................................
............................................................................
............................................................................
State :
............................................................
District :
............................................................
Pin :
............................................................
iv)
: ............................................................................
v)
: ............................................................................
(Inwords.........................................................................................................................................)
vi)
: ............................................................................
vii)
: ............................................................................
viii)
25.
.................................(year
...................................................................
......................% of marks.
It is also certified that the student has not changed the course of study and/or the School/College/
Institute of the study for which the scholarship was originally awarded/has changed the course of study
and/ or school /college /institute with prior approval of the State Government (Please strike out which is
not applicable.
Date :
.............................
Place
..............................
Signature of Head
of the school/college/institute
with official seal
Annexture - I
...........................................................................................................................................................
(Father/Mother/Guardian) of
...........................................................................................................................
.........................................................................................................
.....................................................................................................................................................
.........................................................
will be withdrawn
Affix
revenue
stamp
Signature
Signature
Student
Date :
(Father/Mother/Guardian)
Residential Address:-
At post
Tq
Dist.