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Online Application Form for

Department of Minorities Development
GOVERMENT OF MAHARASHTRA
Form of Appliction for Scholarship Scheme for Minority(Muslim,Christan/Parsi/Buddhist/Jain/Sikh) Community Student for
pursuing Technical and Professional studies
For Official Use Only : Renewal
Whether
Application ID. Year Course
Approved
M10012550 2010 DIPLOMA EN

1.Personal Details
a. Full SHAIKH MOHSIN ALIMODDIN
Name

b. Father's / Husband's Name :ALIMODDIN c. Mother's Name :NASEEM

d. Domicile State : MAHARASHTRAe. Nationality : INDIAN
f. Religion : MUSLIM g.Tel / Mobile: 9769348877

h. Correspondence Address : i. Permanent Address :

3RD FLOOR,B.I.T CHAWL,LOVE MILLNATH NAGAR NEAR FALLAH DARAN
LANE,MAZGOAN,MUMBAI. MADRASA,DHULE

j. Date of Birth : 02-11-1990 k. Gender : MALE

2. Details of educational qualifications from matriculation/SSLC/SSC onwards
YearOf
University/Board/Examina
Examination Passed Passin Percentage
tion
g
SSC MAHARASHTRA STATE BOARD 2008 78.46
Previous year examination details for Renewal of Scholarship.
Marks
Out
Last year Exam Obtain Percentage
of
ed
Diploma EN Second Year 1076 1700 63.29

3. Total Annual Course Fee : Rs. 8900.00/-

Fee Type Fee(Rs.)
TUTION FEES 6000.00
DEVELOPMENT FEES 1000.00
LIBRARY FEES 100.00
OTHER 1800.00
4. Details of Bank Account of Candidate :
a. Payee Name : MOHSIN b. Bank Account No 60041875081
ALIMODDIN :
SHAIKH
c. Bank Name : BANK OF d. Account Type : SAVING
MAHARASHTRA
e. Bank Address : f. MICR Code : 400014002
g. Branch Code No : h. Electronic ECS
Transfer Mode :
i. IFS Code : MAHB0000002

5. Annual Income Of Parent/guardian : Rs.193714/-

6. Details of Course :
Course Name Duration in Studying In Academic Year
Year(s)
DIPLOMA IN ENGINEERING THIRD YEAR Third Year 2010-2011
Basis of Admission in Professional / Technical Course : Marks
SSC Passed with in Maharashtra :
7. College / Institution Details :
College Name : D3005 M. H. SABOO SIDDIK POLYTECHNIC, MUMBAI
Address : 8, SABOO SIDDIK POLYTECHNIC ROAD,
Recognized by TECHNICAL EDUCATION
Authority :
Affiliated University : MSBTE
Tel. No : 23084881 Fax No : 23070924 E-mail :
8. Documents Enclosed with the Application :
i) One copy of passport size photograph with signature.
ii) Attested certificates of educational qualification as filled up in para 2.
iii) Income declaration-affidavit on Rs.10/- non-judicial stamp paper / Income certificate from the employer. or
Rs. 10/- Revenue Stamp will also be permitted
iv) Proof of permanent residence.(Domicile Certificate/ Ration Card/Driving Lincense/Electrict bill/Indian
Passport/Election ID/Telephone Bill etc)

9. Declaration
i) I hereby declare that the information given above is correct.
ii) I am not availing any other scholarship for this purpose from any other sources.
iii) I shall abide by the terms and conditions for sanction of Scholarship for Minority Student for pursuing
Tecnical & Professional Studies.
iv) I undertake, that if at any stage, it is found to the satisfaction of the sanctioning authority in the Ministry of
Minority Affairs 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 liability for such penal action as warranted by law.

Signature of Candidate
Place : Date : ( SHAIKH MOHSIN ALIMODDIN )

Instructions :
You are persuing Technical/ Professional course. Hence please submit your printable form to your
Institute M. H. SABOO SIDDIK POLYTECHNIC, MUMBAI
( Proforma is filled by the Institute / College Head with official seal)
Office Use Only
10. Verification of information to be furnished by the Head of Instituion / College
It is certified that the information filled above by Shri / Smt. / Kumari MOHSIN ALIMODDINSHAIKH S/O.
D/O, W/O Shri ALIMODDIN who is admitted in course DIPLOMA EN THIRD YEARfor the academic
year 2010-11 in college is correct.
For Renewal of Scholarship:
It is certified that the above mentioned student has passed the Diploma EN Second Yearexamination
for
2009-2010 (year) and has attained 63.29 % of marks.

It is also certified that the student has not changed the course of study and/or the institution of the
study for which the scholarship was originally awarded/has changed the course of the study and/or
institution with prior approval of the state government(Please strike out which is not applicable)
Date :
Place :
Signature of the Head of Institution / College with official seal.
Print Application Form

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