Sl. No. of application

Year Class Income

       

Fresh   Renewal  

Male Female Other

                       

SCHEME OF PRE-MATRIC SCHOLARSHIP 2015-16 FOR STUDENTS BELONGING TO THE MINORITY COMMUNITIES

    

 FOR OFFICIAL USE ONLY

FORMAT OF APPLICATION

CLASS 1st to 8th

  Affix a self‐ 

attested 

passport size 

photograph  

    

Part – I [To be filled up by applicant.]  

1. Full name (in block letters):

 

(Tick) √

 

     

2. Father’s Name:      

3. Mother’s Name:    

4. Distict:

5. Full Address for Correspondence:      

6. Contact:  

Mobile  

Email ID   

7. Date of birth :  

D D M M Y Y Y Y                 

8. Whether male or female or other:  

  

9. Aadhaar No. (if available)

 

(Tick) √

Day scholar Hosteller        (Tick)√

Govt/Govt Aided   Private        (Tick)√Day scholar   Hosteller   

10. Nationality:  

  

11. Religion:  12. Details of school/institute, including residential ones:  

(i) Class in which studying:  

………………………………………………………………………………………………..  

(ii) Name of school:  

………………………………………………………………………………………………… Whether School Government/Govt Aided or Private

(iii) Address of school:  

………………………………………………………………………………………………..  

(iv) Details of examination last passed:   

Class last attended

Name of school Marks obtained Total Marks Percentage of Marks

 

13. Whether Day scholar or Hosteller:  

 

14. Total Annual course fee: Rs……………..  

(Break up of course such as Admission fee, Tuition fee and Maintenance Allowance) S.No. Item Amount (Rs.) 1. Admission Fee  

2. Tuition Fee  

3. Maintenance Allowance  

  Total   

15. Details of bank account of student:

Account can be self/Mother/Father         

(i) Account Holder Name as in the Bank Record……………………………. (ii) Name of the Bank …………………………….

(iii) Bank Branch (full address)

State District Pin (iv) Branch Code number ……………… (vi) Bank Account Number

(vii) Type of bank Account Saving/Current

(viii) IFS code of the Bank  

16. Annual Income of parents/guardian of the students: Rs…………

17. Documents enclosed with the application:  (i) Self-attested passport size photograph with signature. (ii) Self declaration of Parental income. (iii) Attested copy of report card of last examination passed. (iv) Photocopy of Bank Passbook. (v) Self declaration of Minority community. 18. Declaration of Student:  

(i) I hereby declare that the information given above is correct. (ii) I am not availing any other scholarship for this purpose from any State/Central Govt. (iii) I shall abide by the terms and conditions for sanction of the Pre-matric Scholarship. (iv) If the information given by me is found to be false/incorrect, the scholarship is 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

 

Date: Place:

   

Signature of the student (Signature/Thump impression of student’s

parents/guardian for students of Class I to V)  

 

Part–II [to be filled up by the Head of the school/institute]  19. Verification/information to be furnished by the Head of school/ institute:  (i) It is certified that the information filled in the above mentioned columns (1 to 17) by Shri/Kumari s/o / d/o Shri who is studying in class

 

for the academic session in this school/institute is correct.

 

 

Date:

Place: Signature of Head of the

school/institute with official seal

DECLARATION BYPARENT/GUARDIAN  

(Parents/Guardian)of……………………….. …………………………(Name of Student) who is studying in Class…………………………school…………………………………. hereby declare that if any stage, it is found that the information given is false/not true, all benefits given to the student under the scheme of “Pre-matric scholarship for students belonging to the minority communities” could be withdrawn and legal action as deemed fit, may be taken against me or my ward.

 

Date:  

 

Signature (Father/Mother/Guardian)

S.No

I 1

2

3

4

Name of Schemes/ programmes

trainees

Documents obtained from students/beneficiaries/

Authorities who collect the documents

II III IV

Educational Schemes: All Scholarship / Fellowship schemes Coaching Programmes Padho Pardesh Scheme

i) Certificate of Religion ii) Family Income

certificate iii) Marksheets of previous

year

Schools/ Institutions/ University Grant Commission/ State or UT Governments/ Banks

Nai Roshni, the scheme for leadership development of minority women

i) Certificate of Religion ii) Family income

Certificate iii)Educational Certificate i) Certificate of Religion ii) Family income

Certificate iii) Educational Certificate

NGOs and other Institutions

Project Implementing Agencies

Seekho Aur Kamao, the skill development initiative

Lending programmes of NMDFC

i) Certificate of Religion ii) Family Income

certificate iii) Marksheets of previous

years in case of educational loans

iv) Any other affidavit

NMDFC and its State Channelizing Agnecies

No.1-9/2014-Media Government of India

Ministry of Minority Affairs

New Delhi, the 21st July 2015

OFFICE MEMORANDUM

Sub.:"Minimum Government, Maximum Governance" — Self Declaration/self certification/self attestation of documents by the applicants in schemes/programmes of Ministry of Minority Affairs, Government of

India.

The undersigned is directed to inform that the self declaration/self certification/self attestation of the following documents shall be obtained from the applicants in following schemes/programmes of Ministry Minority Affairs with immediate

effect:

2. All the Authorities as mentioned in column-IV above in the table, are requested not to insist on attestation of above mentioned documents by the Gazetted Officer or any other Authority unless it is required by Law.

_.2/p.

:2:

3. The necessary format for such self certification/self attestation have already been uploaded on the Ministry's Website and on National Scholarship Portal.

4. This issues with the approval of Competent Authority.

( nurag Ba)j. )aii) p-,,,,pkrectoy

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n "ntr"" Copy to: y„ ;isi r,v; ni Tr- TVik..-.0v ,

1. Joint Secretary (PP)/ Joint Secretary (SS), Ministry of Minority Affairs, to issue necessary instructions under educational schemes, Seekho Aur Kamao and Nai

Roshni.

2. All Directors/Deputy Secretaries, Ministry of Minority Affairs for compliance.

3. Principal Secretaries/Secretaries, Minority Welfare/Social Welfare Departments,

all States/UT Governments. They are requested to issue the necessary instructions immediately to all the District Level Authorities and Schools/institutions for compliance.

4. Secretary, University Grant Commission, New Delhi.

5. Managing Director, National Minorties Development and Finance Corporation to take necessary action immediately under intimation to this Ministry.

6. Managing Director, Canara Bank to issue necessary instructions to all the Banks

extending educational loans.

7. Director (NIC), Ministry of Minoroity Affairs, with a request to upload it on the Ministry's website. He is also requested to upload the formats provided by various Divisions under the relevant programmes in this regard.

8. Center for Good Governance, responsible for National Scholarship Portal.

9. All NGOs/Project Implementing Agencies participating in programmes of Ministry

of Minority Affairs.

Copt/ for information to:

1. Secretary, Deptt. Of Administrative Reforms and Public Grievances, Government

of India, Sardar Patel Bhawan, New Delhi.

2. PS to Hon'ble Minister of Minority Affairs.

3. PS to Hon'ble Minister of State for Minority Affairs.

4. Sr. PPS to Secretary (MA). 5. Press Officer, Ministry of Minority Affairs.

(Anurag Bajpai) Director

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SELF DECLARATION OF FAMILY INCOME UNDER SCHOLARSHIP SCHEMES OF

MINISTRY OF MINORITY AFFAIRS, GOVERNMENT OF INDIA

I, ____________________________Son/Daughter/of___________________________

Resident of (full address)__________________________________________________

______________________________________________________________________

do hereby solemnly affirm and declare as under :-

a) That I am citizen of India.

b) That annual income of my family from all sources is Rs ………………(in words

also) ……………………………………………………………………………………

c) I declare that my father/mother/both* is/are earning Member(s) in my family.

2. I certify that the above information given by me is true.

3. In case this information furnished by me is found false, the financial assistance

awarded to me may be recovered with penal interest and I will be liable to a legal action

against me in accordance with law.

Signature of Candidate:__________________________

Name of Candidate: ____________________________

Name of School/Institution:_______________________

Enrollment No. in the School/Institution:_____________

Academic Year:________________________________

*Strike off the non-applicable part in the underlined clause above.

SELF DECLARATION OF MINORITY COMMUNITY BY STUDENTS

DECLARATION

I, ____________________________Son/Daughter/of________________________

Resident of (full address) __________________________________________________ ______________________________________________________________________

hereby declare that I belong to the___________________________________________

(Muslims/Sikhs/Christians/Buddhists/Jains and Zoroastrians (Parsis) which is a notified

minority community as per Section 2(c) of National Commission for Minorities Act,

1992).

Date:__________

Place:_________

Signature of Candidate: ______________

Name of Candidate: _________________