FORMAT OF APPLICATION FORM

Application No./IDNo.(to be filled by Ministry)--------

1. Name of the Candidate------

2. Father’s/Mother’s Name--------

3. Date of Birth----

4. Place of birth/state

5. Community------

(please attach proof of Community certified by the Competent

Authority)

6. Name of the Examination Passed (Passing of Preliminary

Examination)-------- Year-------

7. Roll Number-----------

(Please attached roll number slip for proof)

8. Identity proof ------------ 8(i) UID No./Adhar no…………….

(Please attached documents for identity)

9. Annual Income of the family from all sources----------

(Income Certificate to be enclosed)

10. Educational Qualifications:

Sl.

No.

Name of the

examination

Board/University Year of

passing

Total

Marks

Total

Marks

scored

%

1 Matriculation

Or equal level

2 Graduation

3 Post

graduation

4 Others( if any)

Attach duly attested mark sheet for each.

11. Bank Account Number(Nationalized Bank only)--------------------------

Bank Name--------------Address of the Bank------------------------MICR

Code----------IFSC Code-------- (Attach copy / photo copy of a

cancelled Cheque of Bank Account with the name of the beneficiary

under the Scheme.

12. Address of the candidates

Permanent Address: -----------------------------------------------------------

------------------------------------------------------------------------------------

Temporary Address:----------------------------------------------------------------

----------------------------------------------------------------------------------------

E-mail id:------- Phone (M) -------- - (Land Line) -------

Candidates need to indicate the address they want the Correspondence to be

sent to. Change in e-mail id; Phone number etc. to be made available.

Signature

Name of the candidate:

Place/Date: