Application for Continuation of

*R-Comm/DA-IICT Merit-cum-means Scholarships

A 201 -1

Student Name Dobariya Hardik P

Student ID 201501038

Program B-Tech ICT

Academic Record

SPI in Winter 201 -1 semester 7.79

CPI at the end of Winter 201 - semester 7.5

Name of Father Pareshbhai Jerambhai Dobariya

Name of Mother Pragnaben Pareshbhai Dobariya

Name of Guardian (if applicable) -

If Guardian, then relationship with the student -

Residential Address of Parents / Guardian

Palasva, Junagadh-362001, Gujarat.

(Tick one that applies : My Parents/Guardian own/rent the above residence)

9. If your Parents / Guardians have taken loan to finance your college education

(a) Loan Amount -

(b) Lending Institution/ Bank Address -

10. Occupation of Father Mother Guardian (if applicable)

Shopkeeper Housewife -

* Tick appropriate scholarship.

 11. Permanent Account Number (PAN) of Father CFHPD1276D

Mother - Guardian (if applicable) -

Family income for the Financial year : April 1, 201 - March 31, 201 80000
Attested supporting documents to be submitted
(tick the appropriate box, as applicable and attach documentary proof in support)
Income from Salary (Financial Year 201 -1 )

Salary slip or Salary Certificate

Form – 16

Income Tax Return

Income from Business / Farming/ Professional Practice / Self Employment (Financial
Year 201 -1 )
Balance sheet and Profit /loss statement

Form – 16A

Income Tax Return

Income from Investments such as Shares holdings, Deposits, Rental Property or any
other income (Financial Year 201 -1 )
List amount and source

Income Tax Return

Bank Accounts statements for the Financial year 201 -1

Income Certificate from appropriate Government Authority

Scholarship committee reserves the right to ask for additional documents.

Declaration: I hereby declare that I have neither applied nor in receipt of any other scholarship of Govt.
of India/State Government/any other agency (e.g. NTSE, TFWS, MYSY, etc.)

Hardik

Date - 14-2-2018 Signature of student

(for Official use)