SCHOLARSHIP APPLICATION FORM

Academic Year Application Date College Name Course Name

Student SSC details

SSC Board Passing Year SSC Seat Number Marks Obtained

Applicant Details
Applicant Name Mothers Name Date of Birth Caste Category Caste Gender Is Applicant Salaried Applicants Annual income Marital Status YES / NO Total Annual Income Orphan Sub Caste YES / NO Disabled Is Resident of Maharashtra YES / NO

Student Prequalifying Details

Last attended School/College/Institute Last Exam Passed Last Exam Passes Year Last Exam Marks

Institution Details
Subject College Admission Number Joining Date Is Fee Paid? YES /NO Receipt Date Fee Amount Paid Is studying at night School? YES / NO Date of Admission

Fee Receipt Number Quota

Management / Government

Bank Account Details

Bank Name Account Number Branch Name

Contact Details
Telephone Number Email Address Address for Correspondence Mobile Number

Pin-code Parent /Guardian Details Name Relation with applicant Profession

Taluka

District

Annual Income

Hostel Details
Name of the Hostel Hostel Admission Date Is Mess Service Available Hostel Address YES / NO Hostel Type Rent per Month

Pin-code Hostel Contact Details Telephone Number Email Address

Taluka

District

Mobile Number

Documents
Caste Certificate Number Caste Validity Certificate Number Income Certificate Number University Registration Number Issuing Office Scrutiny Committee Date of Issue

DECLARATION
The information furnished by me is complete and correct. I bear the complete responsibility for all the above information provided.

Applicants Signature Parents Signature Principals Signature