Application Part - A

Application No. (______________)

(for official use)

PART - A

(To be filled up by the candidate)

Name of the Candidate:
Name of the State:
Residential Address:
Institutional Address:
Male/Female:
Educational Qualification:
Name of the Board/University:
Course applied for
Duration of Course
Type of Disability
Percentage of Disability
Academic records (Attach Copy of certificate and Marks sheets - matric & above): Page No. _____
Family Income Certificate/Proof of Annual Income e.g. salary slip, last income tax assessment order: Page No. ____
Attested copy of Disability Certificate: Page No. _____
Course fee receipt (if any) with break up of each item duly paid during the academic session: Page No. _____
Hostel Certificate or Certificate from the house owner in case of accommodation hired by at least by a group of 3 students living together with common mess arrangement. (Certificate should be submitted in original): Page No. _____

*(Photo copies of the documents from S.No.12 to 15 should be attested by the Gazetted officer)

(Signature)

(For official use)