LUCKY SHIKSHAN SANSTHAN,

E.S.I. HOSPITAL ROAD, KAMLA NEHRU NAGAR, JODHPUR

MERIT CUM NEED BASED SCHOLARSHIP FORM

Sr. No.

Name of Course in which admitted: ____________________ Batch : ___________ Date :_______________

Name of College: ____________________________________________________________________________

1. Name of Candidate: ____________________ ______________________ _________________________

(First Name) (Middle Name) (Surname)

2. Gender (Male/ Female): ________________________ Date of Birth: ______________________________

3. Father’s Name: Mr. __________________________________________________________________
4. Permanent Address: _____________________________________________________________________
Village/ Town/ City: _________________________ Dist. ________________________
State: _________________________________ Pin: _______________________
Landline No.: STD Code: _______ Phone No:___________ Mobile No.: ______________________
5. Father’s Occupation & Address: ________________________________________________________________
________________________________________________________________
6. Father’s approx. annual income: Rs. _________________________ per annum
7. Educational Qualification:
Photocopy
Exam/ Board/ Year of Aggregate
School/ College submitted
Course University Passing % age
(Yes/No)

Class X

Class XII

Graduation

Others

Forwarded by:

__________________ ____________________________________________
Signature of Student Signature of Director/ Principal/ Head of Institution
Name: Seal:

Sr. No. Date : _______________________

For Office Use only:

Recommended / Rejected

The applicant, Mr. / Ms. ______________________________________ of Class /Course______________________

for session /batch /sem. _____________ is hereby sanctioned scholarship / Fee waiver of amount Rs. ___________

(In words _____________________________________________________).

Admission No. _____________________

Receipt No. _______________ Date : _____________

__________ __________
[Treasurer] [Secretary]