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Sl. Of Application Academic Year Course Standard
Group: Primary Upper
Primary: Secondary		 Whether Approved :- Yes    No
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students personal Details

Full Name Date Of Birth :
Father's / Gaurdian Name Age / Year : Occupation:-
Mother's Name Age / Year : Occupation:-
Address Of Correspondance
      Pin Code :-
Phone No Email:-
Gender Male    Female Religion
No. Of Family Member No. of Brother and Sister
Residence is Own Rental Living With Relative  

Educational Details

Examination Passed Year Of Passing Board / Institution Percentage

Total Annual Course Fee in Rs.

Tution Fee: Dev. Fee: Books / Stationary: Other Expenses:
Total Amount Amount In Words:
Monthly / Annual Income Of
Guardian Of the Students in Rs. and Words:

Students / Guardians / Parents Bank Details

Name Of The Bank Account No.
Account Holder Name MICR Code
Branch IFSC Code Bank Address

Assets Details

Home ( Rented Self ) Tv DTH Fridge Automobile SmartPhone
Monthly Electricity Bill Bank Balance(FDs)

Reason For Economical Dependency

Father Expired Father Permanently Sick / Critically Sick / Handicapped Poor Income Large Family
Drunkard / Drug Addict Any Other (Specify)
Brief Description Of Family / Problem Of the Family
Name of NGO/TRUST helping the family / student (if any)
Quantum of help received per annum in Rs. and Words

Student Details

School Name School address
Pin No
Phone No. Email:
Is the School/Instution recognized by Gov?t Yes No Govt. aided / Unaided
If No then by which Authority?

Documents Enclosed With the Application

1. Attested Certificates of Educational Qualifications as filled in para 2
2. Declaration of family income / Income Certificate from Employer
3. Proof of permanent address (Domicile/Ration card / Driving License / Electricity bill / Indian Passport / Election ID / Telephone Bill etc) :

Declaration

* I hereby declare that the infomation given by me is correct.

* I shall abide by the terms & conditions for the sanction of scholarship for me.

* I undertake if the information given by me is false or if I violate the terms and conditions of the scholarship, the scholarship sanctioned to me will be cancelled and entire amount will be recovered and I would have no future chance to get any help from IRCT-PSF.

 

Survey Result

Name Of Surveyor
The student ID eligible / Not eligible for scholarship
Attached Documnets 1 2 3
Date Signature

Approved By IRCT 

The student ID eligible / Not eligible for scholarship Amount
Amount In Words