Indian Institute of Technology Guwahati

Guwahati - 781 039

Form No.
Schp/04
FORM TO CERTIFY/FORWARDING OUTSIDE SCHOLARSHIP

Name Roll No
Programme: Department: Latest CPI / % in
qualifying marks
E-mail ID: Contact No: Enclose a copy of
Category: Gen/OBC/SC/ST latest grade
sheet/marks sheet
Fathers Name Fathers
Occupation
Mothers Name Mothers
Occupation
Parents annual Income
Father’s Employers Mother’s
Address Employers Address

Permanent Address Hostel Name

Room No

Name of the Scholarship and session

applying for
Sponsored Organization & Address
(With Email ID & Ph. No)
Amount of Scholarship (state whether Last Date for submission to
sponsorer
p.a./p.m./one time)
Status (Tick): Renewal/Fresh
In case of renewal, state year & amounts received:-
Are you a recipient of any other scholarship(s)?
If yes, please mention the name of the scholarship, session and amount.
No of Enclosures submitted to certify
Specify whether the Scholarship will be received directly from sponsoring authority / through
IITG?
Declaration: I do hereby declare that the above information is true to the best of my knowledge.

Date of submission:
Signature of student:
Date of received
For Official Use
Verification from Academic Affairs: Remarks from SA Section:
(In case of M.Tech/M.Des/Ph.D students)