AKSHARAM EDUCATIONAL FOUNDATION

BRINDAVANAM, 7 TEN DOWNING, CBI Colony 1st Main Road, Perungudi, Chennai 600096 India.

APPLICATION FORM REQUESTING FINANCIAL ASSISTANCE TO PURSUE EDUCATION

Application Number (For Office Use Only):

Name of the Applicant: Date of Application: Date of Birth (DD/MM/YYYY) Sex: (M/F) Email Id: Father/Guardian Name: Applicant Details Permanent Address: Current Address: Contact Residence Number: Contact Mobile Number: Contact of Father/Guardian: Contact of any other close relative: SNo Family Members 1 2 3 4 5 6
Page 1 of 4 Phone: 044-42803920 / 9940224284

Paste Passport Size Photo Here

Family Member Name

Relationship

Marital Status (Married/Single/W idowed/Divorced)

Educatio n/Occupa tion

Website:www.aksharam.org.in Email: admin@aksharam.org.in

AKSHARAM EDUCATIONAL FOUNDATION

BRINDAVANAM, 7 TEN DOWNING, CBI Colony 1st Main Road, Perungudi, Chennai 600096 India. SNo 1 2 3 Course Completed School/University Marks Obtained Year of completi on

Course for which financial assistance is sought for Financial Status of the Family

Education attained so far

(Please attach copy of supporting documents showing details of course to be pursued) Course/Class Name: School/University: Address of School/University: Phone Number of School/University: Reference from the School/University: Starting date of education: Expected course completion date: Amount of Scholarship/Financial Assistance sought for: Estimated Financial Need till completion of Course:

(Please attach copy of supporting documents, if any, demonstrating financial challenge) Number of earning members in the family: 1. Earning Member Name / Relationship Working With / As / Since Monthly Salary 2. Earning Member Name / Relationship Working With / As / Since Monthly Salary Any other relevant information:
Website:www.aksharam.org.in Email: admin@aksharam.org.in

Page 2 of 4 Phone: 044-42803920 / 9940224284

AKSHARAM EDUCATIONAL FOUNDATION

BRINDAVANAM, 7 TEN DOWNING, CBI Colony 1st Main Road, Perungudi, Chennai 600096 India. Other educational assistance/loans taken (provide information if any): Educational assistance/loans taken by You: Educational assistance/loans taken by your brother/sister: Any other relevant information: Other Comments/Remarks regarding the Financial assistance required:

SNo. Reference Name Reference 1 2 3 4

Address, Phone Number, Email Id

Known since

Details of the person who referred you to Aksharam: Name of the Person: Address: Phone Number: How do you know him:

Page 3 of 4 Phone: 044-42803920 / 9940224284

Website:www.aksharam.org.in Email: admin@aksharam.org.in

AKSHARAM EDUCATIONAL FOUNDATION

BRINDAVANAM, 7 TEN DOWNING, CBI Colony 1st Main Road, Perungudi, Chennai 600096 India. Attachments (Please tick the attachments provided along with this application) 1 Recent Passport size photograph Details of course to be pursued Copy of Academic marksheets Copy of Transfer Certificate (TC) Copy of Conduct Certificate Salary certificate of parents Copy of ration card Letter from person who is referring to Aksharam

_______________________ (Signature of the Applicant) For Official Use Only:

____________________________________ (Signature of the Father/Guardian/Referrer)

Page 4 of 4 Phone: 044-42803920 / 9940224284

Website:www.aksharam.org.in Email: admin@aksharam.org.in