C£ÀħAzsÀ-C

2017-18 £Éà ¸Á°£À C®à¸ÀASÁåvÀgÀ PÀ¯Áåt E¯ÁSÉAiÀÄ «zÁå¹j ¤ÃqÀĪÀ ¸À®ÄªÁV ¸À°è¸ÀĪÀ Cfð £ÀªÄÀ Æ£É
(ªÀÄĹèA, Qæ²ÑAiÀÄ£ï, eÉÊ£ï, ¹Sï, ¥Á¹ð. ¨ËzsÀÞ ¸ÀªÄÀ ÄzÁAiÀÄzÀªj
À UÉ ªÀiÁvÀ)æ

UÉ,
f¯Áè C¢üPÁjUÀ¼ÀÄ,
C®à¸ÀASÁåvÀgÀ PÀ¯Áåt E¯ÁSÉ/
¨sÁªÀavÀæ
»AzÀĽzÀ ªÀUÀðUÀ¼À ªÀÄvÀÄÛ C®à¸ÀASÁåvÀgÀ PÀ¯Áåt E¯ÁSÉ (¸ÁÖA¥ÀÄ ¸ÉÊdÄ)
_____________________________ f¯Éè

vÀªÄÀ ä ¥ÀæPÀluÉ ¸ÀASÉå: C¸ÀA¤/«zÀå¹j/¹Dgï-06/2015-16 ¢£ÁAPÀ:15/10/2015 ¥ÀæPÀluÉAiÀÄAvÉ

C®àà¸ÀASÁåvÀgÀ «zÁåyðUÀ¼À «zÁå¹j ªÀÄAdÆgÁw PÉÆÃj Cfð ¸À°è¸ÀÄvÉÛãÉ. £À£Àß «ªÀgÀUÀ¼ÀÄ F PɼÀPA
À qÀAvÉ EzÉ.

Religion :
ªÀÄĹèA Qæ²ÑAiÀÄ£ï eÉÊ£ï ¹Sï ¨ËzsÀÝ ¥Á¹ð
Tik √
(zÀ¥ÁàPÀëU¼
À À°è) °AUÀ
M F
Name ( in Capital) Gender
: vÁ¬Ä :
Father Name Mother Name

Address

Taluk / District
: Pin Code ªÉÆèÉÊ¯ï ¸ÀASÉå
Mobile NO
10£Éà vÀgÀUÀw CxÀªÁ Board : Register (Hall Ticket) No.
vÀvÁìªÀÄ Pass year
th
,10 Std or Equivalent

/Present College :

«¼Á¸À :
Taluk. District.
Present College Address
/Course Year,

, Admission / Reciept No ¢£ÁAPÀ/ Receipt Date

Tik √ Day Residential :

Hosteller Regular Correspondence
Suitable Scholar College Mode of Education
ªÀµÀð/ / «ªÀgÀ Total MlÄÖ
Details of Previous Year/Course / Class Passed Marks (Max) Marks Obtained Percentage

ªÁå¸ÀAUÀ ªÀiÁqÀÄwÛÃgÀĪÀ Q «Äà UÀ¼À°è

Distance from Native Place to Present College in KMs - Address Proof – Ration Card, Voters Id, Adhaar, BPL etc
ªÀÄvÀÄÛ DzÁAiÀÄ ªÀÄvÀÄÛ Income Category ¤ÃrzÀ ¸ÀܼÀ/
DzÁAiÀÄ ¥ÀæªÀUÁð
Caste & Income Certificate Number & Date Issuing Place

Bank Name: ¨ÁæAZï /

Branch:
1
Student Bank Account No
ಐ. . . . /IFSC Code:
.ಐ. . .UID
(Aadhar) No. if available
Caste & Income Certificate
ªÀÄvÀÄÛ DzÁAiÀÄ ªÁ¸À¸Àî¼ÀzÀ /Ration Card
Bank Pass Book zsÁR¯ÁwUÁV
EªÀÅUÀ¼À°è
PÀqÁØAiÀĪÁV AiÀiÁªÀÅzÁzÀgÀÄ ZÀÄ£ÁªÀuÁ UÀÄgÀÄw£À Voter ID
®UÀwÛ¸À¨ÉÃPÁzÀ Previous Course Marks Card MAzÀÄ
zÁR¯ÁwUÀ¼ÀÄ/ : zÁR¯ÁwUÀ¼À£ÀÄß Aadhar Card
Should be SSLC Marks Card ¸À°è¸ÀvÀPÀÌzÀÄÝ
Certificates to be . . . . :
Enclosed Attach any one of
zÀ the following for Any Other Document (if available)
¥ÀæªÀiÁt ¥ÀvÀæ/ ¥ÀrvÀgÀ aÃn/ªÁ¸À zsÀÈrPÀgÀt
residential proof
¥ÀvÀæ/ZÀÄ UÀÄgÀÄw£À aÃn EvÁå¢.
Distance certificate /Ration Card/
Voters ID/Adhaar Card (Any One)

I. Declaration
I hereby certify that above information furnished is true I have not availed any other scholarship for this
purpose from any other sources. I shall abide by the terms and conditions of the sanction of the scholarship. If
any discrepancies are found later, I hereby abide for refund of the scholarship amounts claimed and also am liable
for action by the Department.

Place
Date: Signature of the Student

II. Verification Report of College Principal

This is to certify that the information above is verified with the records and found to be correct. He / She is a
bonafide student of our college studying in ____________________________ (Course & Course Year) during
2017-18 academic year.

Place
Date: Signature of the Principal
(with College Seal)

Note: Completely Filled Applications along with necessary documents should be submitted to
District Office, Minority Welfare Department/Backward Class Welfare Dept of respective District
where college located.