GOVERNMENT OF KARNATAKA DIRECTORATE OF MINORITIES

FRESH ( ) RENEWAL ( )

PRE-MATRIC SCHOLARSHIP 2013-14 FRESH & RENEWAL

Ministry of Minority Affairs, Govt. of India Scheme & Govt. of Karnataka Scheme (For Jains)
For Students belonging to the Minority Communities - Muslims, Christians, Sikhs, Buddhists, Parsis & Jains

For students of 1st to 10th Standard only.

1. The students have to submit the filled in applications only to the Head Master / Principal of their respective schools on or before 05.08.2013 2. In turn the Head Masters/Principals have to submit the applications along with the list of the candidates in the prescribed format available on the website www.gokdom.com to the concerned Block Educational Officer (B.E.O) on or before 14.08.2013 3. The Last date to submit the list of students (soft copy) by the concerned Block Educational Officer (B.E.O) to the Directorate of Minorities is on or before 05.09.2013

PART - I (TO BE FILLED BY THE CANDIDATE) Full Name (in Block Letters as per school register)
Affix recent color passport size photograph (do not staple)

Details of Parents/Guardian ( in Block letters) Fathers Name Guardians Name Fathers/Guardians Occupation Annual Income of Parents/Guardian Parent/Guardian Mobile No. Date of Birth
(As per school records)

Place of Birth

Gender
(Mark by Tick)

Religion

Nationality

Male ( ) Female ( ) School Address : (IN CAPITAL LETTERS)

Name and address of the school

PINCODE : SCHOOL DISE CODE Academic & Fee Details
Examination Passed during 2012-13

TALUK :

DISTRICT :

Percentage of Marks Obtained

Class Studying during 2013-14

Annual Fee for the year 2013-14 (in Rs.)

TUITION FEE (a)

ADMISSION FEE (b)

TOTAL FEE (a+b)

RENEWAL DETAILS
How to check if a student must apply as Fresh or Renewal for the year 2013-14 ?
Visit www.gokdom.com. On the Right Hand Side the Pre-Matric Scholarship 2012-13 FRESH FIRST LIST, FRESH SECOND LIST & RENEWAL LIST are published. If the students name appears in any of these 3 lists then, such student must apply as Renewal (Check the Renewal Box at the top on this page ) & also fill the details asked below. Does your name appear in the sanctioned FRESH/RENEWAL lists of 2012-13 published on www.gokdom.com ? Yes ( ) No ( ) If yes, Amount Sanctioned _____________ Master Sl. No. ____________________

10 digit Pre-Matric Permanent ID Allotted : www.gokdom.com Page 1

Home Address: ( IN CAPITAL LETTERS)

PINCODE :

TALUK :

DISTRICT :

Bank Details and Account Number of the Student: (Compulsory for BOTH FRESH & RENEWAL Applicants) (i) Name of the student (as in the Bank Account) : _______________________________________________________ (ii) Saving's Account Number : Please enter the complete 12 or 14 or 16 digit Account No. in the above box (iii) Bank Name : _______________________________________________________________________________________ (iv) Branch Name : _____________________________________________________________________________________ (v) IFSC Code :
Please enter all 11 digits correctly. Contact the Bank Manager for the IFSC Code.

Note : If you are opening a new bank account to fill the above details, make sure that the Bank has an IFSC code and then open the bank account. Generally all Nationalized banks have an IFSC Code.

CONDITIONS (1) Only Students who have scored not less than 50% marks in the previous final examination may apply. (2) In case of 1st Standard students, 50% marks requirement will not apply. Only the income criteria will be applicable. (3) The annual income of the students parents/guardian from all sources should not exceed Rs.One lakh. Documents to be enclosed (attached) with the application (i) Photo of the student must be pasted on the first page of this application. (ii) Xerox Copy of the Caste & Income Certificate issued by Tahsildar or (iii) Original Affidavit on non-judicial stamp paper of Rs.20/- as per the format given on Page 4 of this Application (iv) A Xerox Copy of the Bank Pass Book (First Page) showing the Account No. Of the student, Student Name, Bank Name and Branch Address has to be enclosed. DECLARATION (i) I hereby declare that the information given above is correct. (ii) I am not availing any other scholarship from any other Government Department. (iii) I shall abide by the terms and conditions for sanction of the Pre-Matric Scholarship. (iv) I undertake that, if at any stage, it is found to the satisfaction of the sanctioning authority in the State Government that the information given by me is false or if I violate the terms and conditions of the scholarship, the scholarship sanctioned to my son/daugher 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 by law.

Signature/Thumb impression of Parent/guardian Place Date : _________________________ : _________________________

Signature of the student

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PART - II [ TO BE FILLED UP BY THE HEAD MASTER / PRINCIPAL OF THE SCHOOL ] Verification/information to be furnished by the Head Master / Principal of the School

(i) It is certified that the information filled in the above mentioned columns by Shri/Kumari ___________________________________________________________________________________________ son/daughter of _______________________________________________________________________________________ who is studying in _____________ standard for the academic year 2013-2014 in our school is correct.

(ii) He/She has secured ____________ percentage of marks in the previous annual examination.

I have scrutinized the documents and verified with the school records and certify that the information furnished above is correct and true to the best of my knowledge, and confirm that no student of other caste other than the above said minority communities is recommended for this scholarship.

Date Place

: ____________________ : ____________________

Signature of the Head Master/Principal of the school With official seal having the complete address of the school

IMPORTANT NOTE:1. If you have the Caste & Income certificate issued by Tahsildar, you can attach a Xerox copy of it attested by a gazetted officer along with the application form. 2. If you do not have the Caste & Income certificate issued by Tahsildar , then type the matter given in Page No.4, on a non-judicial stamp paper of Rs.20/- and get it attested by a Public Notary and attach the original to this application. 3. DO NOT attach any Original documents with this application. Only Income Affidavit in Original has to be enclosed.

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( Affidavit to be submitted Only if Income Certificate Issued by Tahsildar is not available)

AFFIDAVIT FORMAT
(To be typed on a Non-Judicial Stamp Paper of Rs.20/- and notarized by Public Notary with Seal & Signature )

DECLARATION OF PARENTS'/GUARDIAN'S ANNUAL INCOME & MINORITY COMMUNITY

I ....................(Father/Mother/Guardian) Of .................................(Name of Student) who is studying in . Standard of ............................................................................................... School ............................................. Place hereby declare that my annual income from all sources is Rs....... (in figures) Rupees....only. I declare that I belong to (Muslim/Christian/Sikh/Buddhist/Parsi/Jain) community. If at any stage, it is found that the information given by me is false/not true, all benefits given to the student under the scheme of Pre-Matric scholarship for students belonging to Minority Communities could be withdrawn and legal action as deemed fit, may be taken against me or my Ward.

Date

: _______________

Signature (Father/Mother/Guardian)

Place : _______________ Address : __________________________________________ __________________________________________ __________________________________________

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