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APPLICATION FORM FOR ATAL BHASHANTAR YOJANA

Please affix a
passport size
photograph which
was taken during the
last six months.

1. Name of the applicant :


(in Block Letters)

2. Age:
(as on 01.08.2019)

3. Present address:

4. Permanent address:

5. Contact number with whatsapp (cell):

6. Secondary contact number (cell):

7. Email id:

8. Class X details:
(name and location of school, pass percentage and self-attested photocopy of
the certificate)

9. Class XII details:


(name and location of the institution, pass percentage and self-attested
photocopy of the certificate)

10. Graduation:
(Course, College and University, pass percentage, and self-attested photocopy
of the certificate )
11. Post-graduation , if applicable:
(Course, College and University pass percentage, and self-attested photocopy
of the certificates )

12. Any additional qualifications :


(Course, institute, pass percentage and self-attested photocopy of the
certificate)

13. Proficiency in Hindi: a) Class XII level b) Graduation level c) higher


( please put a tick mark and submit self-attested photocopy of the certificate)

14. Proficiency in English: a) Class XII level b) Graduation level c) higher


( please put a tick mark and submit self-attested photocopy of the certificate)

15. Proficiency in foreign language

a) Language :

b) Level : a) Graduate or equivalent b) Post-graduate or equivalent c) higher


( please put a tick mark and submit self-attested photocopy of the certificate)

c) Details of the institute/ University:


(at all levels )

d) Pass percentages:
(all levels)

Declaration

I hereby declare that entire information furnished in this application form is correct. In
case any of the above entries are found incorrect, then my candidature may be
summarily rejected by Ministry of External Affairs.

Place: ………………………..

Date: (Sign along dotted lines)