PART-II

CENT VIDYARTHI
(For Common Application Form, Guarantors Consent Letter & Acknowledgement-Please fill PART-I.) BASIC INFORMATION

Sl Particulars a. Proposed course of Study b. Duration of Course c. Name and address of the College /
Institution in which the student intends to join.

Details
Years Full time Part time

d. Name of the University/Recognised

Authority to which institute is affiliated. the

college/

e. Has the student been admitted into the

f. g. h. i. i.

above College /Institute / University or accepted for the Course? If so, certified copy of admission/ acceptance Letter should be attached Is the applicant attending any college or Institute at present? If so, furnish full particulars. No. of earning members in the Family & their total income. Whether the student has any working experience? If yes, please give details. Whether the student will take up any part-time employment during study? If yes, please give details. Year of retirement of father Guardian (if in service only)

CENT VIDYARTHI STUDENTS ACADEMIC RECORD:

Name of the examination from SSC or equivalent onwards Name of the School/ College Medium of instruction Examination authority Month & year of passing Whether passed in the first attempt Aggregate marks first attempt Out of total marks Percentage of marks Rank/Class/Div obtained Scholarship/ Prizes won for academic distinction. (Certified copies of the list of marks of all the above exams should be enclosed) PARTICULARS OF FINANCIAL REQUIREMENT OF THE COURSE Studies in India Rs. Studies in abroad Rs. Admission fee Total fees for ______ per year Term Fee for ___years Books, stationery, instrument & equipment Books, stationery, Boarding & lodging @ instruments, ___________ per year for equipment _____________ years examination fees Boarding & loadging Total i.e. Equivalent in Rs. @ Rs.______ per month for ________ years Total (enclose Air passage (one way only) evidence)

Total (enclose evidence)

CENT VIDYARTHI
SOURCE OF FINANCE:
1. 2. 3. 4. 5. Non repayable scholarship(s) at Rs._____________ p.a. for ____________ years Loan scholarship(s) and or other repayable financial assistance from other sources Contribution of Parent/ Guarding and /or other Members of the family / relatives towards total expenses Amount of loan required from the bank Earning of the student(if any) Total Rs.__________________ Rs.__________________ Rs.__________________ Rs.__________________ Rs.__________________ Rs.__________________

Particulars of Insurance Policy (ies) (In the case of father/ guardian/ applicant only) Names of the insured Policy No Date Date(s) of Amount of Date of last Maturity yearly premium premium paid

ADDITIONAL INFORMATION TO UNDERTAKING STUDIES ABROAD

a. b. c. d. e. f.

BE

FURNISHED

BY

STUDENTS

Amount of foreign exchange required. Foreign currency Rupee equivalent Have you obtained the necessary passport, /visa etc? Yes/No.(if yes, give reference) Do you intend to take up any part time employment during the course of studies abroad? If so, give particulars. What are your likely Prospects on your return to India?

DECLARATION: We hereby declare that the information furnished against the foregoing items is true to the best of our knowledge and belief. We also undertake to inform the bank immediately any change in our employment details, address, telephone number including mobile no. etc. for both local and permanent address, Signature of Father/Guardian Place Date Signature of student Signature of Guarantor (if any)