APPLICATION FORM
PERSONAL INFORMATION
Candidate’s Name
Father’s/Guardian’sName
Mother’s Name
Telephone No
Mobile No. (Parents mobile no. can be provided):
Email:
DomicileState/UT(State/UTwhichthestudentbelongsto):
DateofBirth(DD/MM/YYYY) Nationality
AnnualFamilyIncome(Rs.) Category: General ST SC OBC
Person with Disability (PwD)? No Locomotor Disability Dislexic Hearing Impairement
VisualImpairment Spastic Autistic
ADDRESS FOR CORRESPONDENCE
City/Town/Village&PO
District State Pincode
Phone Mobile
PERMANENT ADDRESS :
City/Town/Village&PO
Affix a self attested
passport size photograph
District State Pincode
Phone Mobile
AnnualFamilyIncome(Rs.)
DETAILS OF EDUCATIONAL qUALIFICATIONS:
Name of the School Studying in
Board School Affiliated with
School Address
City/Town/Village&PO
State Pincode
School Telephone No.(Including STD code)
School Email-ID
Principal’s Name Principal’s Mobile
Presently Studying in: Class XI Class XII
EXAMINATION PASSED
BOARD YEAR OF PASS OVERALL CGPA/PERCENTAGE
SUBJECT GP/ PERCENTAGE
Class X
Class XI(ForclassXIIstudents only)
Given in CGPA or Percentage?
CGPA Percentage
Maths: Science:
Physics : Chemistry :
Maths:
DETAILS OF OThER EXAMINATIONS /TEST CLEARED
NTSE Maths Olympiad Science Olympiad KVPY NSEJS NBHM Other
DETAILS OF BANk ACCOUNT OF STUDENT
Name of the Bank
Branch address
Bank Account No.
IFSC/RTGS/NEFTCode(11DigitAlphanumericCodeoftheBank)
Preference of city in which you want to attend the contact classes (choose from the list of cities given in the brochure)
1
2
3
Annual Income of parent/guardian of the student : Rs (SpecimenformofdeclarationofannualincomeisgivenatAnnexurewhichistobesignedbytheparent/guardianofthestudentandenclosedalongwiththeapplication.Incaseparent/guardianareemployed,incomecertificatefromtheemployer may also be enclosed)
Documents enclosed with the application(i) One copy of passport size photograph with signature.(ii) Selfattestedcertificatesofeducationalqualificationasfilledupinpara09.(iii) Income declaration - affidavit on non - judicial stamp paper and income certificate from the employer.
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 the merit-cum means based scholarship.(iv) I undertake, that if at any stage, it is found to the satisfaction of the sanctioning authority 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.
Date : Signature of the candidatePlace :
FOR OFFICIAL USE ONLY
Sl No. of Application Year Class Gen/SC/ST/OBC
Annexure
DECLARATION OF FAMILY INCOME
I...............................................................................................(Father/Mother/Guardian)of........................................
............................................(Name of Student) who is studying in ..............................................................................
...........herebydeclarethatmyannualincomefromallsourcesisRs./.........................................inword......................
......................................................................................................if at any stage, it is found that the information given
bymeisfalse/nottrue,allbenefitsgiventothestudentundertheschemeof“UDAAN”couldbewithdrawnandlegal
action as deemed fit may be taken against me or my ward.
SignatureDate :(Father/Mother/Guardian) ResidentialAddress
UNDERTAkING BY PARENT
I ......................................................................(Father/Mother/Guardian) of .....................................................have
understood the terms and conditions of the Udaan program and agree to abide by them. I promise to support my
daughter for the duration of the program and will ensure that my daughter sincerely participates in the program.
I also understand that as part of this program my daughter will be required to attend contact classes on the weekend at
a centre appointed to her. I will support her in attending these classes.
I agree to ensure the safety of the tablet and study material given to her and promise to return the same in the event she
discontinues from the program.
Date:
Signature:
Name: