FORM TO BE COMPLETELY & CORRECTLY FILLED BY ELIGIBLE FRESH

ENTRANTS FOR SCHOLARSHIP AND REFUND OF FEE

(From Samaj Kalyan/ Pichhada Varg Kalyan/ Alpsankhyak Kalyan Vibhag, U.P.)
Category. Caste..Religion
Name of Institute: ...................
Group: A

Board (10th Class) ........

Roll No. (10th Class)...................................Year of passing (10 th Class).

Paste
Recent
Photographs

Date of birth (On the basis of High School Certificate)........................................................

Scholarship Year .
Full Name of Student.Gender (Male/Female).......
Fathers Name .
Mothers Name ...
Monthly Income of Guardian from all sources (Rs.) .Annual Income (Rs.)..........
Day scholar Hosteller
BranchYearSession..
Course ..
Id. of Economically Weaker Family..
Duration of CourseDate of Class Registration.
Permanent Address ...
Phone...
Address for Correspondence .....
Phone...
Banks Name: Indian Overseas Bank
Branch: GLA Engineering College, Ajhai (Mathura)

Account No. ......

Scholarship Amount.Amount of fee refund..

Particulars of earlier Scholarship:
Year of passing of High School (X Class) ... Scholarship received: YES/NO
Year of passing of Intermediate .. Scholarship received: YES/NO
Year of passing of Graduation Scholarship received: YES/NO
Year of passing of Post-Graduation Scholarship received: YES/NO
Year of passing of Diploma . Scholarship received: YES/NO.
or Any other Exams ....

Signature of Legally Valid Guardian

Date

Signature of Student

Signature of Class Advisor

Date.

Signature of Director
(SEAL of Institute)

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