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- APPENDIX - 1
- To download the form
-
- GOVERNEMENT OF ORISSA
- C.D. & R.R. DEPARTMENT
- SCHOLARSHIP FOR THE DISABLED
- Application form for fresh
scholarship
- Application must the Collector
of the concerned district not later than…………………
-
- PART –I
- ( To be filled in by the
candidate )
-
-
- 1. Nature of physical handicap
:
- 2. Name in full
: Shri/ Smt./ Km.
-
( In block letter )
- 3. Postal address to which communication should
-
be sent.
:
- 4. (a) Are you a citizen of India ?
:
-
(b) District and State to which you belong
:
-
(c) Whether scheduled Caste/Tribe
:
- 5. Date of birth
:
-
( In Christian era )
- 6. Name and address of the
parents/guardian and Name of the parent/guardian
……………..
- Relationship of the guardian
with the applicant . …………………………………………
-
Profession………………………………
-
Address…………………………………
-
Relationship of guardian ……………….
-
………………………………………….
- 7. Total
monthly income to both the parents/
-
Guardian .
- 8. Please sate , if you are
earning an income : Yes/No
-
If yes, please indicate
-
(i)The source
- 9. (a) Particulars of all
examination passed ( commencing with the middle or equivalent examination.
-
-
- -- --------------------------------------------------------------------------------------------------------------------------------------------------------------
-
Name of
Year
Subjects
Name of Name of
-
Examination
taken
Institution
Board /
-
University
-
(1)
(2)
(3)
(4)
(5)
- -- --------------------------------------------------------------------------------------------------------------------------------------------------------------
-
-
-
-
(b) Percentage of marks obtained in the last
-
examination passed (Enclose Mark list).
-
( In the case of examination in music , indicate
-
division obtained ).
-
- 10. Have you ever received scholarship under the Yes/No.
-
Scheme
?
-
(i) Class in which scholarship last awarded
……..
-
(ii) Period for which scholarship was paid
……..
-
(iii) Sanction / Reference No.
-
- 11. please state whether you have undergone
any
-
training course at any training center for adult
-
blind/ deaf approved by the Centre / State
-
Government.
-
- 12. (i) Course of study for which
scholarship is now
-
desired, mention class.
- (ii) Date of
commencement of the course
……
-
(iii) Approximate date of termination of the
-
Course.
-
(iv) Exact date of joining
the present standard /
-
Class in the course during the
current academic
-
Year.
13. For blind ---
-
Have you engaged a reader?
……
-
If yes , please indicate --
…….
-
-
(i) Amount paid per month
…….
-
(ii) Date of engagement
…….
14. Documents attached
-
(i) ……
-
(ii) ……
-
(iii) …..
-
(iv) …..
-
(v) …..
-
-
-
-
-
I hereby declare-
-
- (i)
that I shall not
accept emoluments, scholarship , stipend , or any other financial assistance or grant in
any other form whatsoever , except examination from tuition fees, from any other source
during the tenure of the Government of India Scholarship , If awarded to me under the
above Scheme.
-
OR
- That I am in receipt of assistance to the tune of Rs. ____________ from _________________ and in
the event of award of scholarship , I undertake to refund it from the month the
scholarship is payable to me , to the source from where I have received it, and that
during the tenure of scholarship , if awarded I shall not received any other financial
assistance , emoluments, Scholarship , stipend or any grant in any form whatsoever except
the exemption from payment of fees.
-
- (ii)
that the statements
made in the application are true to the best of my knowledge and belief and that no
material information having a bearing on
selection has been concealed or withheld.
-
-
-
-
-
-
Counter signature of
Signature of the Candidate
-
Gazetted Officer of
-
Central / State Govt. /
- M.P./ M.L.A. /
Magistrate/
- Head
of the Institution .
Counter
Signature
-
of the
guardian , in case
- Place :
the candidate is minor
-
- Date :
-
-
-
-
-
-
-
-
-
-
- PART II
-
- ( To be filled by the
Head of Institution )
-
- 1. (a)
Is the candidate enjoying free board and / or,
- loading
facility or any other concession in
- kind from any other source ?
-
(b) If so , indicate the monthly amount
-
equivalent to the
concession.
- 2. Is
the candidate residing in an hostel attached
- to School/
College / Establishment ? If so , date
- from which
residing .
- 3. (a)
details of the nearest branch of Reserve
-
Bank of India / or State Bank of India or
a
-
subsidiary Bank
affiliated to the State Bank
-
of India , where Government business is
-
transacted.
-
(b) The designation of an officer in
whose
-
favour Demand Draft
may be remitted.
- For Orthopaedically Handicapped.[FrontPage HTML Markup Component][FrontPage Component][FrontPage
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- (i) (a) Is the candidate using any
prosthetic
-
appliance (s) used.
- (b) If so,
please indicate the nature of
-
appliance (s) used.
- (ii) (a) Is the candidate using special
transport
-
to and from the Institution ?
-
(b) If so , please indicate clearly the mode
-
of transport and the
approximate
-
distance traveled daily.
- For Blind –
-
Has the candidate engaged a Reader ?
-
If so , the monthly amount paid to him /
-
Her and the date from which engaged.
-
-
-
Certified that –
- (i)
The information
given by the applicant in Part I has been checked and found , correct .
- (ii)
This institution is
affiliated to the University of …………………….and / or
is recognized by the Government of ……………… and the course of
study / training is recognized by that University/ Government.
-
- No.
Signature of the Head of the
-
Institution.
-
Name …………………………
-
( In block letters)
- Place :
Designation ………………….
-
Address………………………
- Date
:
PIN ………………………
-
( Seal of the Head of the Institution )
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