GOVERNMENT OF KARNATAKA DIRECTORATE OF MINORITIES

PRE-MATRIC SCHOLARSHIP 2012-13 (FRESH & RENEWAL)

(Ministry of Minority Affairs Govt. of India Scheme)
For Students belonging to the Minority Communities - Muslims, Christians, Sikhs, Buddhists & Parsis

For students of 1st to 10th Standard only.

1. The students have to submit the filled in applications only to the Head Master / Principal of their respective schools on or before 31st July 2012. 2. In turn the Head Masters/Principals have to submit the applications along with the list of the candidates in the prescribed format available on the website www.gokdom.com to the concerned Block Educational Officer (B.E.O) on or before 11th August 2012. 3. The Last date to submit the list of students (soft copy) by the concerned Block Educational Officer (B.E.O) to the Directorate of Minorities is on or before 31st August 2012.

PART - I (TO BE FILLED BY THE CANDIDATE) Full Name (in Block Letters as per school register)
Affix recent color passport size photograph (do not staple)

Details of Parents/Guardian ( in Block letters) Fathers Name Guardians Name Fathers/Guardians Occupation Annual Income of Parents/Guardian Date of Birth
(As per school records)

Place of Birth

Gender
(Mark by Tick)

Religion

Nationality

Male ( ) Female ( ) School Address : (IN CAPITAL LETTERS)

Name and address of the school

PINCODE : Academic & Fee Details
Examination Passed during 2011-12

TALUK :

DISTRICT :

Percentage of Marks Obtained

Class Studying during 2012-13

Annual Fee for the year 2012-13 (in Rs.)

TUITION FEE (a)

ADMISSION FEE (b)

TOTAL FEE (a+b)

RENEWAL DETAILS
Did you receive the Pre-Matric Scholarship by the Directorate of Minorities during the year 2011-2012 Yes ( ) No ( ). If yes, Amount Received : ________________.

10 digit Pre-Matric Permanent ID Allotted : This ID has been allotted to all Fresh & Renewal students selected in the year 2011-12. If you do not know, please visit www.gokdom.com www.gokdom.com

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Home Address: ( IN CAPITAL LETTERS)

PINCODE :

TALUK :

DISTRICT :

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 : Please enter the complete 12 or 14 or 16 digit Account No. in the above box (iii) Bank Name : _______________________________________________________________________________________ (iv) Branch Name : _____________________________________________________________________________________ (v) IFSC Code :
Please enter all 11 digits correctly. Contact the Bank Manager for the IFSC Code.

Note : If you are opening a new bank account to fill the above details, make sure that the Bank has an IFSC code and then open the bank account. Generally all Nationalized banks have an IFSC Code.

CONDITIONS (1) Only Students who have scored not less than 50% marks in the previous final examination may apply. (2) In case of 1st Standard students, 50% marks requirement will not apply. Only the income criteria will be applicable. (3) The annual income of the students parents / guardian from all sources should not exceed Rs.1 lakh. Documents to be enclosed (attached) with the application (i) Photo of the student must be pasted on the first page of this application. (ii) Xerox Copy of the Caste & Income Certificate issued by Tahsildar or (iii) Original Affidavit on non-judicial stamp paper of Rs.20/- as per the format given on Page 4 of this Application (iv) For Renewal Students only - Xerox Copy of the Pass Book (First Page) or any document from the bank carrying the Account No. Of the student, Student Name, Bank Name and Branch Address. DECLARATION (i) I hereby declare that the information given above is correct. (ii) I am not availing any other scholarship from any other source. (iii) I shall abide by the terms and conditions for sanction of the Pre-Matric Scholarship. (iv) I undertake that if, at any stage, it is found to the satisfaction of the sanctioning authority in the State Government 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 Parent/guardian Place Date : _________________________ : _________________________

Signature of the student

www.gokdom.com

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PART - II [ TO BE FILLED UP BY THE HEAD MASTER / PRINCIPAL OF THE SCHOOL ] Verification/information to be furnished by the Head Master / Principal of the School

(i) It is certified that the information filled in the above mentioned columns by Shri/Kumari ___________________________________________________________________________________________ son/daughter of _______________________________________________________________________________________ who is studying in _____________ standard for the academic year 2012-2013 in our school is correct.

(ii) He/She has secured ____________ percentage of marks in the previous annual examination.

I have scrutinized the documents and verified with the school records and certify that the information furnished above is correct and true to the best of my knowledge, and confirm that no student of other caste other than the above said minority communities is recommended for this scholarship.

Date Place

: ____________________ : ____________________

Signature of the Head Master/Principal of the school With official seal having the complete address of the school

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 in Page No.4, 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 or Xerox Copy of Marks Card or Address Proof documents with this application.

www.gokdom.com

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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/Parsis) community. If at 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 Pre-Matric 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

: _______________

Signature (Father/Mother/Guardian)

Place : _______________ Address : __________________________________________ __________________________________________ __________________________________________