fio be submitted in 6 copies alonqwith citizenship & marksheets)

Generalscholarship
Scheme2016-17[

Scheme2016-17[ I
I/SAARCScholarship

Gourseappliedfor:
FirstnameMiddlename

Lastname

1 .N a m e
2. Father'sName/Occupation
:
3. FullCorrespondence
Address

4. District
5. Phone/Mobile
No.

6. E-mail
7. Dateof birthin Christianera

8. Ageas on 01 July2016

9. TotalMarksin classXll

Years_Month

MarksObtained
in classXll

Days

% in ClassXll

10.MarksObtainedin Englishin classXll:

11. lfurther understand
that mere nomination
of my name by EOl, Kathmandudoes not
guarantee
admission
to any Indiancollege/university
for the abovecourse.I will not request
for changeof college/institutionor transferof scholarshipupon taking admission.I will
not reiecUwithdraw scholarshipseat at a later stage after placementin any institution in
Indiafailingwhich Embassymay debarmy candidaturefor futurescholarships.
12. I certilythat information/details
furnishedare correctto the bestof my knowledgeand belief.
I am alsoawarethatmy application/selection/scholarship
willbe rejected/
annulledat anystage
if anyfactsstatedaboveare foundto be incorrecV
incomplete.

Signature
withdateof submission

TNDIAN
COUNCTL
FORCULTURALRELATIONS
ii

DearApplicant,

Thankyou very much for your interestto pursuehighereducationin India.As

you prepareto apply for the $cholarshipof ICCR,it is requestedto keep in mindthe
following:-

Pleaseread the instructionbeforefillingout the forms.Pleasealso readthe

financialtermsand conditions.

lt.

form whichshouldbe tvped or hand

The completedand signedapplication
written alongwith otherattachments
mustbe e-mailedas a .pdfdocumentto
the Embassy/High
Commissionof Indiain your country.As hard copy along
with 6 photographsshould also be delivered to the Embassy/High
Commission
of India.

ilr.

Pleasenotethat yourapplication
will be consideredonlyafterit is verifiedand
recommended
by the Embassy/ Highcommission
of lndia.

lv.

Please note that your placementto a particulareducationalinstitute/

Universitywill dependon the availability
of seatsand the coursethat you are
choosing.Therefore,beforefiling your three choices,you are advisedto
checkthe Institutions/Universities
availablefor the disciplinethatyou intendto
study. You may like to see a list of InstitutionslUniversities
where ICCR
scholarsare studyingat present.

V.

Pleasedo notethat once you acceptadmissionto a particulardisciplinein a

particularinstitution,
subsequent
changeseitherin the institution
or discipline
wouldnot be possible.

vl.

Ple?se nptg that no admlpsion and scholarship is offered for MBB$ / MD

/ MS / BDS courses.

*lt

INDIANCOUNGILFORCULTURALRELATIONS
AZADBHAVAN,INDRAPRASTHA
ESTATE,NEW DELHI-11OOO2

APPLICATION
FORMFORICCR
SCHOLARSHIPS
FORFOREIGN
NATIONALS
FORTHEACADEMIC
YEAR2016.17
PleasetickScholarship
Schemefor whichapplication
is beingmade:

sl.

Scholarship Schemes
GeneralScholarshipScheme(GSS)- ICCR

()

()

()

()

()

()

()

()

- MEA
(MGC)Countries
for students
fromMekongGangaCo-operation
Scholarships
- ICCR
SriLankaScholarship
Scheme- NehruMemorial
Scholarship
NehruMemorial
Schemeto Sri Lanka- MEA

()

Maulana
AzadScholarship
Schemeto Sri Lanka- MEA

10 ()
11

()

12 ( )
13 ()
14 ()
15 ()
16 ()
17 ()
18

()

EducationExchange
Scholarships
underbilateralCulturalExchangeProgrammesi
- ICCR
(CEP/EEP
Proqramme
Scholarship)
(ICCR'sCommonwealth
for students
fromCommonwealth
Countries
Scholarships
Scholarshio
Plan)- ICCR
- MEA
Scholarships
for studentsfromAfricanCountries
- MEA
for studentsfromSAARCCountries
Scholarships

RajivGandhiScholarshipSchemeto Sri Lanka- MEA

Bangladesh
Scholarship
Scheme- ICCR
- MEA
lndiaScholarship
Scheme(Bangladesh)
(alsoknownas SilverJubileeScholarship
for Nepalese
nationals
Scholarships
- MEA
Scheme)
Medicine
AYUSHScholarships
to studyIndianTraditional
Systemssuchas Ayurveda,
(available
for studentsfromall Countries,
thoughpriority
Unani,Siddha& Homeopathy
is qivento BIMSTEGGountries)- MEA
AYUSHScholarships
to studyIndianTraditional
Medicine
Systemssuchas Ayurveda,
(available
for studentsfromall Countries,
thoughpriority
Unani,Siddha& Homeopathy
is qivento Non BIMSTECCountries)- Avush
AYUSHScholarships
to studyIndianTraditional
MedicineSystemssuchas Ayurveda,
Unani,Siddha& Homeopathy
to Malaysiannationals- Ayush
- MEA
to Afghannationals
Scholarships
Scholarshipsto Mongoliannationals- MEA

20

()

- MEA
nationals
Scholarships
to Bhutanese
- MEA
Scholarships
to Maldivian
nationals

21

()

- ICCR
ICCRCulturalScholarship
Scheme(ForDance/Musicl/oga/Art)

19 ()

22 ( )
SpecialScholarshipSchemeto Mauritiannational(TCDMEA) - ICCR
oov.in
/.rccr.gov.rn
For iurther snecifications of each Scheme-, mav
may refer to ICCR Website www.iccr
Pleasetickone of the followingcourseoptions:(

) U G(

) P G(

)Ph.D(

)Ayush

TO BE FILLEDIN BY MISSION
ANDATTACHED
TO EACHCOPYOF APPLIGATION

ICCRSCHOLARSHIP
APPLICATIONS
1.

Application
formbeingusedis for the rightacademicyear.

()

2.

dulyfilledin and properlytaggedare sentherewith

Siqcopies/setsof the application

()

3.

Scholarship
schemehasbeenselected/tickedproperlyby the scholar

()

4.

Course/University
optionhasbeenproperlyindicatedby the scholar

()

5.

There are six recentpassportsize photographs,

five pasted(one on each form with
photograph
pasted
signature)
andoneadditional
not
to anyform

()

6.

certificates/
marksheets
Certifiedcopieshavebeenattachedof the syllabiand graduation
qualification
for all educational
listed

7.

Marksheets
requiredby the studentto qualifyfor his
etc.for the minimumqualifications
courseof choicehavebeenattached

8.

Synopsisof proposedarea of researchhave been attachedby the studentwho is

applyingfor doctoral/postdoctoralcourse

9.

Thisapplication
is for a B.E.courseand hasthe confirmation
the candidate
has taken
(PCM)in his/herschoolleavingexaminations
Physics,Chemistryand Mathematics
(mandatory
requirement)
for Engineering
courses

10.

Video/audiocassettesof studentswishingto studyperforming

Artsare enclosed.

()

11.

of documents
whichare not in Englishare attached
Certifiedcopiesof translations

()

12.

attachedwiththisapplication
Certifiedthatno originaldocuments

()

13.

Certificate
of Physicalfitnessis attached

()

14.

are attached
Characterrecommendations

()

15.

Englishskillsareattached
Certificate
by Missionincluding
certification
of student's

()

16.

Certifiedcopiesof relevantpagesof passportareattached

()

17.

of ICCR
hasbeengivenby studentthathe willabideby termsandconditions
Undertaking
scholarships

()

18.

Gertifiedthat student has not beengiven ICCRscholarshipbefore

(Note: lf s/he has already availed of an ICCR scholarship,please attach HOM's
recommendation
as to why s/heshouldbe givenscholarshipfor the secondtime)

()

19.

Gertifiedthat studentis not alreadystudyingin India

(Note:lf student is alreadystudying in India,pleaseattach HOM'srecommendation
as to why s/he should be convertedinto an IGGRscholar)

20.

Certifiedthatapplication
formis completein everyrespect
Signature
Name

Designation
Mission

CERTIFICATETO BE FURNISHEDBY THE INDIAN DIPLOMATICREPRESENTATIVE

Certifiedthat lam satisfied
that Mr./Mrs./Miss

(Nameof candidate)
is permanently
domiciledin

(Nameof country)
andon completion
of his/ her
studiesin lndiawillreturnto

(Nameof the countryof domicile)

form havebeencheckedwith the originaldocuments

and that
Certifiedthat all entriesin the application
the applicationis completein all respects. Attestedcopiesof certificates,diplomasor degreesof
passedare enclosed.
examination

Certifiedthat the candidate'sknowledgeof Englishis sufficientto enablehim/herto followlecturesand

givenin Englishandto takeexaminations
in thatlanguage.
instructions

Date

Signature

Place

Designation

INSTRUCTIONS
TO CANDIDATESFOR FILLINGTHE APPLICATIONFORM
1 All entries (except the signature)in the applicationshould, be typewrittenor handwrittenin
blockletters(capitals).
2 Six copies of application, duly filled and properly tagged, are to be submitted.
3 Each copy should be complete in all respects,with all the required information and all
necessary supporting documents, as listed below:
i.

A recent passport size photograph (taken not earlier than a year before the date of the
application)should be pastedon the applicationform in the space providedfor the purpose.
The nameshouldbe writtenon the photographfor purposeof identification.

ii. Apart from these six photographswhich are to be pastedon the applications,one additional
photograph,not pastedto any form, must be supplied.
iii. Certified copy of the syllabi, curricula, etc. of courses covered in schools, colleges,
universitiesattended(exceptthe Senior Cambridge,High Cambridgeand LondonGeneral
Certificateof Educationexamination)with full details.Note: lf this informationis not supplied,
your applicationwill not be considered,as this informationis requiredin order to establish
equivalencywith Indianacademicstandards.
iv. Certifiedphotostatcopies of all academicqualificationscertificatesand marksheets,including
those relatingto school leavingexamination,which are mandatoryfor the coursefor which
you have applied.
Note: Please ensure that certified copies of documents showing specific qualifications
required for the course of your choice (such as GMAT scores for admission in
MBA/TOEFUIELTS scores for English courses etc.) are also attached. The
requirements can be checked from the UGG website / Handbook or from the
website of the institution concerned.
v. A certificateof physicalfitness in the prescribedform.
vi. Recommendations
/ charactercertificates
as requiredunderS. No.15of this form.
vii. Certifiedcopies of relevant pages of candidate'svalid passport (max validity),showing
photograph,name, contactdetails,date of issue,date of expiry and place of issue.(Note:
Pleaseensurethat your passportis valid for the durationof the coursefor which you have
applied.)
(oRrGlNALDOCUMENTSSHOULDNOT BE SENTW|TH THE APPLTCATTON
AS THESE
wtLL NOT BE RETURNEDTO THE APPLTCANT.)

APPLICATIONFORM

Spacefor recent
passportsize
photograph

1 . Fullname(lN BLOCKLETTERS)

(Mr./Mrs./Miss)
2. Male(

)Female(

3 . Contactdetails:i . Tel:
i i . Fax:
iii. Email:
iv. Postaladdress:

4. Permanent
homeaddress(lN BLOCKLETTERS)
5. Dateof birth

Nationality

6. Countryof residence
7. PassportNo.
i . Dateof issue
iii. Placeof issue
L Detailsof Father/ Guardian
Name:
Relation(F/G):
Occupation:
Nationality:

ii. Dateof expiry

Addressof permanent:
residenceof Father/ Guardian

9. Knowledgeof proficiencyin English

Fair( )
Good ( )
Written
(
F a i r( )
Good
Spoken
)
gradesobtained.
passed
English
and
in
examination
Specifylevelof

Poor(
Poor (

)
)

Poor(
Poor(
Poor(

)
)
)

of any otherlanguage
10.Knowledge

Written
Spoken
Understand

Good
Good
Good

Fair(
Fair(
Fair(

)
)
)

)
)
)

11. Give details,if any

(a) Proficiencyacquiredin games,sports& athletics;and
or socialactivities
(b) Parttakenin otherextra-curricular
/ Institutesin Indiain which you seek admission:
12. Statein orderof preferencethe Universities
1.

2.
3.
Missionin
of India"avaihblewith the IndianDiplomatic
Handbook
NOTE:Pleasereferto "Universities
Pleasenote
(UGC)websiteat http://www.ugc.ac.in
GrantsCommission
yourcountryor go to University
as listedby
universities
onlyfor coursesin centralor stategovernment
scholarships
thatICCRprovides
by UGC.
whichhavebeenapproved
the UGC,andfor coursesin deemeduniversities
of
In caseof non-availability
/ Institution.
in yourchoiceof University
of admission
Thereis no guarantee
other
to
a particularcourse in a particularlnstitution,the Councilwill forward the application
wheresuchcoursesareavailable.
Universities/lnstitutions
However,
as per theirchoiceof course/institute.
the candidates
The Councilwouldtry to accommodate
in Indiaevenif theseare
for any courseor institution
the rightto offeradmissions
the Councilreserves
may decidewhetheror no to accept
preferred
choice.Whilethe candidate
not amongthe candidate's
will be
suchan offer,it may be notedthat once accepted,no changein eithercourseor University
permitted.
13.Statein orderof preferencethe coursel whichyou would like to study in India.
1.

NOTE: Gandidateshould be very specific and clear about the course of study, which he /
sfre wistres to pursue in India. Scholarships are not available to pursue more than one
course. Gandidate should ensure that the courses listed here are offered by all three of
the Universities listed under S.No.12 above. The candidates must refer to the
Universities/lnstituteWebsite to know the eligibility criteria for the courses of their
choice.
6

14.PREVIOUSEDUCATIONALQUALIFICATIONS
(Fillin all columnswhich are applicableto you):

Country

Certificate
/ Degree

Yearof
Percentage
Graduation

Nameof School/
Universitv/ Board

SchoolLeaving
(equivalent
to GradeXll in
India)

n-r-ft

Undergraduate
(equivalent
tothreeyearscourse
aftergradeXll in India)

|-T.-n

Postgraduate
(Twoyears'Masters'course
after

n-[n

theabovementioned
undergraduate
or fiveyears'
Masters'courseaftergradeXll)

[rr-l

Acceptedl-l
(Ph.D)
DOCTORAL
(AfterMasters'
Degree)

Trl-n

Not yet
accepted |

Note:Detailsof anv
anycoursein lrrdianUniversities tstituteswhich the
in pastmaybe givenbelow.
Year

OR

Nameof University/ Institute

currentlyattending
or hasattended
Cource

15'Givebelowthe namesof two personswho haveagreedto testifyfromtheirpersonalknowledge your

to
character(theymustnot.berelatedto you and shouldhavedirelt moweogSoivow academicpursuits
andattachrecommendation
letters/ charactercertificates
signedby them).
(a) Name
Status/Designation
Address
E-mail
(b) Name
Status/Designation
Address
E-mail
16.Detailsof closerelative(s)or friends,if any,in India.
l.
ll.
lll.
lV.
V.
Vl.

Name
Relationship
Status/Designation
Address
TelNo.
E-mail

17. Have you travelledor lived in India in the past. lf so, mentionplacesvisited and dates

of such visits.

18.Haveyoueveravailedof ICCRScholarship
earlier?lf so, pleasegivefulldetails.
(i) Yearof Scholarship
(ii) Nameof Course
(iii) Nameof the lnstitute/ University
(iv) Totalduration
of stayin Indiaon scholarship
19'Anygeneralremarkswhichyou wouldliketo offer(if the spaceis not sufficient,aftacha separate
sheet
andsignthesame).
Date
Place
Signature
of Applicant
I herebydeclarethatthe particulars
givenaboveare true to the bestof my knowledgeand belief,that I
haveunderstood
the termsand conditionsof the Scholarship
Schemeas giuenaboveand in Annexures
II and III and herebyundertaketo abideby them,and that ialso undertalieto retumto my country
after
completion
of mystudiesin India.

Signature
of Applicant

Annexure-l
CERTIFICATEOF PHYSICALFITNESS
(To be filledby a Registered
Medicalpractitioner
in the applicant's
countryof domicile)
Nameof Applicant
Sex M/F
MaritalStatus
Age

BloodGroup

Nationality
Address
(city)
(Country)
Telephone
No.
EmailAddress

l.

whichmayadversely
MedicalHistory(Pleasegivedetailsof any pastmedicalcondition
impactthe patient'shealthat the currenttimeor in the nearfuture).

lA. Historyof AnyKnownlllness/ Surgery:RaisedBP-

Yesn

Nol-l

- Yes n
lf, yes- on Regular
treatment

No E

DM-

Yesl-l

Nol--l

- Yes l--l
lf, yes- on Regular
treatment

No E

IHD-

Yesl--l Non

- Yes n
treatment
lf, yes- on Regular

No n

Stroke-

Y"sl-l

- yes [-l
lf, yes- on Regular
treatment

No E

ruol-_l

Kidney
Disease:
ChronicRenalFailure- Yed-l Nil

lf, yes- on Regulartreatment- Yes [-l

Nol-l

(morethan2 weeks)
Any historyof Surgery/ prolongedhospitalization
withduration
of illness/
treatment
Yes/No;
if yes,detailsof illness
/ injury/ surgery

Any historyof lossof appetite-

Yes n

No [-l

Any historyof lossof Weight-

Yes l-l

No [-l

Any historyof digestivediseases-

Yes l--l

No E

FamilyHistoryof :

DMT-I

HT E

obesity
l-_l

Any knownAllergy:-

lf so, is the patienton any medication

/ precautions?

ll.

Physical Examination

Medicalcondition
of:Height

Weight

Chest
Lungs

Head

Eyes.

Pharynx-HeartReflexes

Remarksif any:ilt.

MedicalExamination:-RoutineBlood,(including
Fasting& P.P),UrineTestand Chest
(to ruleout anychronic
X-Rayand any othertestas deemedfit by the MedicalPractitioner
disease).

tv. Summary
1.

I believethisapplicantlS / lS NOTphysically
ableto carryon a full courseof study,involvinglong
hoursof work,in a collegeor university
in lndia.

2.

In myopiniontheapplicant's
healthandphysicalcondition
in generalare:
Excellent

Good

Poor

10

3.

I certifythat the applicantis up-todateon routinevaccinations

including,amongothers,MMR,
DPT,Varicella,HepatitisA & B etc.

4.

He/ Shehasno physical

/ alimentwhichwouldhinderhimfrompursuing
condition
a fullcourseof
studyin India.
()

5.

He / She presentno evidenceof any communicable

diseaseor of any chronicfatigue.
()

6.

He / She does not have any chronicmedicalconditionwhich requiresregularand sustained

medicaltreatment.
()

NOTE:lf answersto 4, 5 and 6 aboveare positive,pleasegivedetailsin Remarkscolumnbelow.

REMARKS

Date

Signature
Address

IMPORTANT:
As a protectivemeasure,those planningto study in India are strongly advisedto get
vaccinatedagainsttyphoid / cholerabeforecoming to India.

LL