Application form for Central Sector Scholarship Scheme (Govt.

of India)
1. Name of Applicant : *2. (i) Institute Roll No. : (ii) Hall & Room No. : (iii) SBI A/c No: 3. E-mail Address : 4. Mobile No. (if any) : 5. a. Name of Father : b. Name of Mother : c. SC ST d. Name of Present Guardian : (his relationship with the student if parents are not alive) e. Name of Brothers and their occupation: Self Attested Passport size Photo

f. Name of Sisters and their occupation:

6. Present Postal Address of Father/Guardian :

ANNUAL INCOME OF FAMILY 7. i) Fathers Gross Annual Income ii) Mothers Gross Annual Income (if any) iii) Annual Income from other source (i.e. Investment in Bank/ Post Office/UTI/LIC/ Share/Debenture/ Landed property/ Income in the name of student, etc., if any) : Rs. : Rs. : Rs.

Total of 7 (i) +(ii) +(iii) above

: Rs:______________

Contd2

8. Fathers/Guardians Occupational Status (Tick as applicable) i) In Service (Govt./Pvt.): (Supported by IT Form16 / Saral Form whose Annual Income Is above Rs.1,10,000/-) ii) Other than Salaried/Pensioner : (Supported by Annual Income Certificate to be issued by S.D.O./B.D.O./M.R.O./TAHASILDER/Local Municipal Corporation/ Gram Panchayet, etc If Businessman/Medical/Legal Practitioner/Consultant etc.: a. Name & Address of Firm / Organisation / Shop : b. Nature of Business/Trade : c. Trade/Professional License/Registration No. : (Copy to be enclosed) d. Sales Tax /Comml.Tax Registration No./Zone : iii) Pensioners/Family Pensioners : (supported by Non-Employment Certificate to be issued by : S.D.O./B.D.O./M.R.O./TAHASILDER/Local Municipal Corporation /Gram Panchayet, etc.) 9. Mothers occupation : (with Address of Employer, if employed) 10. Declaration : I declare the following: i) No disciplinary action has been taken against me by the Institute in the preceding session 2006-07. ii) I am not in receipt of any other Scholarship/Stipend /Fin. Assistance, etc. from any other source. Form A is enclosed Form B is enclosed

Form Cis enclosed

signature of the father/ guardian with date

signature of the student with date

Encl. : 1. 2. 3. 4.

Attested copy of 10 & 12 Certificate Income Certificate Proof of Permanent Residence Cast Certificate

* Keep it blank

FORM A

Annual Income Certificate for those Parents/Guardians who are in Service

(Govt or Pvt.) PART - I Income from Salary 1. Name and Address of the Employer: 2. Certified that ____________________________________________ is employed in this Organisation in the capacity of (Designation / post held by the Employee)_______________________________, and that the break-up of his/her Gross Annual Income from Salary received in the Financial Year_____________ is as follows:

Item

Total Amount for 12 months

i) Basic Pay: ii) D/Pay: iii) DA/ADA/Relief: iv) Special Pay & Honorarium, Bonus, etc., if any: v) Other Allowances if any:

Rs. Rs. Rs. Rs. Rs.

Total

Rs.:________________

Employers Signature : Designation: Date :

(Official Seal) N.B. : All the entries as stated in Column 2 above must be supported by attested copy of IT Form 16 / SARAL Form for the corresponding year. Guardians whose annual gross income is below Rs.1,10,000/- need not submit IT Return. They have to submit a certificate from Employer / Salary disbursing officer stating that their annual income is Not Taxable and they need not produce IT Form 16.

Contd2

:2: PART II Income from other sources

(Declaration by the Father / Guardian of the Student)

I declare that my familys Annual Income from other sources during the Financial Year ____________________ was as follows :

Income from : a. Landed Properties: (Certificate from Tahsilder/Gram Panchayat) b. Agriculture: c. Investment in Bank/Post Office/Unit Trust etc.: d. Share Certificates/Debentures: e. Other sources: Total: Rs.

Rs. Rs. Rs. Rs. Rs.

Further I declare that the information given above is true. I understand that the Central Sector Scholarship for SC Students if awarded to my son/daughter, is liable to be withheld or discontinued at the discretion of the authorities of the PDPM Indian Institute of Information Technology, Design and Manufacturing Jabalpur, without assigning any reason. If subsequently it is found that he/she has been granted any other Scholarship/Stipend /Fin. Assistance, etc. by any Govt./Non-govt. organization for the same period, I shall be bound to refund the whole amount of Scholarship/Free ship/Stipend/Financial Assistance, etc. to the scholarship awarding authority immediately. I shall also be personally held responsible for the refund of the Scholarship/Free ship amount (paid to my son/daughter by the Institute) in the event of any information in this declaration and also in the enclosed scholarship application form, being proved Incorrect later on.

Date : Signature of the Father /Guardian: Full Name: Address with Pin Code:

Phone No., if any:

FORM B Format of Income Affidavit (For use of those Parents/Guardians who are not in employment anywhere and derives income from sources other than Salary/Pension)

(To be submitted on Non-Judicial Stamp paper of Rs.20/- and sworn in before a First Class Magistrate/Notary Public)

I, Shri/Smt.__________________________ a resident of _______________________solemnly declare that : 1. My son/daughter, Shri/Miss ______________________________ is currently studying at the PDPM Indian Institute of Information Technology, Design and Manufacturing Jabalpur, in 4year B.Tech Program in ____________________________________Engineeing. 2. He/She is an applicant for the award of Central Sector Scholarship for SC Students Scholarship for the Academic Year ________________. 3. I declare that my spouse is employed / not employed and that the Annual Income of my family in the Financial Year____________ i.e. during the period from 1st April, _______to 31st March, _______ was as mentioned hereunder (Supported by document) : (A) From my own profession as indicated : i) Income from Business/Medical practice Legal Practice/Engineering Consultancy etc. ii) Income from Agriculture iii) Income from Landed Properties iv) Income from Investment in Bank/ Post Office etc. v) Income from Share Certificates/Debentures vi) Income from any other sources(i.e. Retirement Benefits for VRS/VSS etc., if any (B) Income of my wife/ (if Rs.___________ any) p.a. (if employed, Salary certificate from Employer to be enclosed) (T) Income in the name of my son/ward (if any) Contd2 Gross total Income (A+B+C) :Rs. _____________ p.a.

Rs._____________ p.a. Rs._____________ p.a. Rs. ____________ p.a. Rs._____________ p.a. Rs. _____________ p.a.

Rs. _____________ p.a.

. Rs. _____________ p.a.

:2: Further I declare that the information given above is true. I understand that the Central Sector Scholarship for SC Students if awarded to my son/daughter, is liable to be withheld or discontinued at the discretion of the authorities of the PDPM Indian Institute of Information Technology, Design and Manufacturing Jabalpur, without assigning any reason. If subsequently it is found that he/she has been granted any other Scholarship/Stipend /Fin. Assistance, etc. by any Govt./Non-govt. organization for the same period, I shall be bound to refund the whole amount of Scholarship/Free ship/Stipend/Financial Assistance, etc. to the scholarship awarding authority immediately. I shall also be personally held responsible for the refund of the Scholarship/Free ship amount (paid to my son/daughter by the Institute) in the event of any information in this declaration and also in the enclosed scholarship application form, being proved Incorrect later on.

(Signature of Father/Guardian)

Sworn before me this _________________ day of ____________________ 200_____ and signed.

(SEAL)

Signature of First Class Magistrate /Notary Public