Passport size Colour photo

SC / SCA / ST (Fresh) Date:…./…../20……

Roll No Scholarship ID

Course Branch Year

Name of the Student

Name of the Father

Date of Birth 19 Gender MALE / FEMALE

Religion Hindu / Muslim / Christian First Graduate YES / NO

Community (as per community certificate)

BC MBC DNC SC ST Caste

Annual Income (as per Income Certificate)

Email ID

Aadhar Card No

Communication Address:

………………………………………………………………….…………

………………………...….………………………………………………

Taluk…………………………..District………………………..PinCode

Student Mobile No. Parent Mobile No

Bank Account Details of the Student

Student Bank Account Number

MICR Code (9 digit code)

IFSC Code (11 digit code)

Hosteller YES / NO Date of Joining at the Hostel (Current academic Year)

Signature of Warden

with seal (if Hosteller) Signature of the Student

Signature of Head of Department

SCHOLARSHIP ONLINE REGISTRATION APPLICATION FORM

Name of the Bank Branch Name