Beruflich Dokumente
Kultur Dokumente
( TF/13/05569 )
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Sex Educational Qualification Name of the Board/University Course in which Studying (current) Duration of Course Type of Disability Percentage of Disability Student Bank Detail Bank Name Bank Branch Name Bank Address Bank Account No. IFSC Code No. Academic records (Attach copy of Certificate and Marks Sheets- Matric & above ) Family Income Certificate / Proof of Annual Income (Criteria<= Rs. 300000 p.a) e.g. salary slip, last income tax assessment order Attested copy of Disability Certificate Course Fee receipt (if any) with break up of each Item duly paid during the academic session Hostel (Certificate should be submitted in original)
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*(Photo copies off the documents from S.No. 12 to 15 should be attested by the Gazetted officer) Signature (For Official use)
(i) Course in which admitted : (ii) Qualification required for the course : (iii) Marks obtained :
Annexure - A
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Others In case of grades, please mention equivalent % of marks and also enclose authenticated conversion formula 7. Family Income per annum (in Rs.) : 30000 Please enclose Income Certificate) 8. (i) Course in which studying: B.TECH (ii) Academic Session : 2013-2014 (iii) Duration : 4 Yrs. (iv) Year in which studying: IIIrd Year 9. Name and address of the institution where KANPUR INSTITUTE OF studying : TECHNOLOGY,KANPUR Address : A-1,ROOMA INDUSTRIAL AREA,KANPUR NAGAR U.P. 208001 District : KANPUR NAGAR State : UP Pin : 208001 10 Whether hosteller or a day scholar please specify: Day Scholar (If hosteller, please specify whether provided by the institution or own arrangement). (please enclose certificate) 11. Details of Scholarship/Stipend/financial NO assistance being received for the same course (if any). 12. Any other information applicant wishes to provide. NO I hereby declare that information provided above is true to the best of my knowledge and I am aware that providing wrong information will make me liable to legal action and recovery of scholarship amount. Date: Place: Enclosures: (i) Academic record attested copies of relevant certificates/mark sheets for the qualifying examination. Name & Signature of the applicant
(ii) Proof of annual income - Proof of income shall include last salary slip of parent/guardian, acknowledgement of income tax/income certificate from revenue official/gazetted officer/public representative e.g. MP, MLA, MLC, Panchayat officials etc.; (iii) Attested copy of Disability certificate; (iv) Course fee receipt if any, duly paid during the academic session; (v) Receipt/Invoice of eligible assistive devices duly countersigned by the authorized signatory of the institution;
1. Certify that ASHUTOSH KUMAR SINGH is studying in course of B.TECH which is (please tick the relevant or specify) Diploma/Degree/PG level study/any other (please specify) studying in and is presently
I Year 4 Yrs.
II Year
III Year
IV Year
2. The information furnished above by the student is in order and correct as per records of the Institution. 3. The family income as per record of the institutions is Rs. 30000 per annum. 4) Intuitional Bank Account Details a)Bank Name : b) Bank Branch Name : c) Bank Address : d) Account No. : e) IFSC Code: (Note: Please provide the Bank Details, so as course fee amount of scholarship shall be transferred in this Account ) 5. The student is receiving scholarship/financial aid/stipend from not receiving any scholarship/financial aid/stipend from any other source as per records of the Institute. 6. General conduct of the student is satisfactory/ unsatisfactory (please strike out whichever is not applicable) 7. It is certified that this institution is recognised by Central Govt. / State Govt. / AICTE / UGC/ RCI or affiliated to recognised university_______________________________. 8. Course Fee for this academic year Rs._______________________________. {Excluding Hostel charges, books / stationary charges and caution money (for hostel and library etc.) }
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