CLAIM FORMAT FOR 2010-11

LIST OF STUDENTS RECOMMENDED BY EDUCATIONAL INSTITUTION

Pre-Matric Scholarship (Fresh / Renewal)

Day scholar / Hostler

Whether
Year of % of total the Savings A/c Details of
fresh marks Annual student is Actual Course fee paid
the Student

Religion
Gender
Class /

(F / M)
S. Name of the Date of Father / Guardian scholarship secured in Income of physically

D/H
Std. in
No. student birth Name santioned final exam parent/ handi
2010-11
(2008-09, during guardian capped Branch Admission Tuition
Name of
2009-10) 2009-10 (Yes / Code fee Fee Total
the Bank
No) No. Rs. Rs. Rs.

Grand Total

CERTIFICATE

1. Applications of the above mentioned students are fully verified with reference to relevant records of Mark Sheet, Community and Income Certificates or Declaration in the
non-judicial stamp paper and actual course fee paid are obtained along with scholarship application (prescribed format) and kept in our educational institution custody.

2. The above said students have not enjoyed any other scholarship from State/Central Government Departments.

3. Scholarship have not been recommended for more than two students in a family including both fresh and renwal scholarship for the year 2010-11
4. The students have secured 50% and above percentage of marks in the previous examination (2009-10)

Details of Bank Account of the a) Name of the Payee : b) Name and Address of the Bank with Branch Code No.
Educational Institution: c) Bank Account No. d) MICR code of the Bank :

Head Master / Principal / Correspondent

Educational Institution Seal Signature of the Head of Educational Institution

Full postal address of the Educational Institution with

Contact Phone No. Designation with seal