Application Form Annex2

w.e.f.5.1.
2016
Annexure II
Application No.
(to be filled by the Foundation)
S R JINDAL SCHOLARSHIP SCHEME

Application Form
(The applicant should enclose documents mentioned under Important Instructions)

1)
Affix Passport
Size Photograph
attested by the
Principal with
Seal
2)
Name in Full (CAPITAL LETTERS)

(as per SSLC/SSC mark sheet)
Date of Birth :
4)
Fathers/ Guardians name
5)
Address for communication
Tel. No Landline (with STD Code)
Mobile
Email-id
Are you physically handicapped or Widow / Ward of
Ex-Serviceman or belong to BPL family (State Clearly)
a) Occupation of Parent / Guardian
b) Annual income of entire family from all sources
(if found wrong, no scholarship but action will be taken)
a) Particulars of last examination passed
b) Marks Obtained / Gross Total Marks
c) Percentage of marks
:
:
:
:
:
a)
b)
c)
a) Course & Semester / year in which studying at present

b) Duration of the course
c) Whether regular or part time or by correspondence
:
:
:
a)
b)... Years
c)
Regular/ Part Time/Correspondence
(Tick () whichever is applicable)
d) Month
Year
a) Name of school/ college/ institute/ ITI in which presently

studying.
b) Address with the name of the state
a)
b)
c) E-mail id
d) Phone No. with STD Code:
:
:
State:
c)
d)
11)
Total fees per year
Rs.
12)
Have you applied previously to us for scholarship, whether

it was sanctioned, if so, reference/file No.
Yes/ No
13)
Whether staying in Hostel run by the College/ Institute

(If yes, what are the charges incurred per month)
a) Are you getting any stipend/ scholarship from any
other source?
b) If yes, amount per month
Yes/No (Tick () whichever is applicable)

Rs.
p.m.
Yes/No
Rs.
15)
Scholarship amount required
Rs per month
16)
Details of the bank account of the student
:
:
:
:
S.B. A/c. No.

Name of the Bank
Branch Address
IFSC Code
I hereby certify that the information disclosed by me is true.

Foundation issued from time to time.
I agree to abide by all the Terms and Conditions of the
6)
7)
8)
9)
3)
Nationality :
:
Rs.
d) Month & Year of Final Exam at the end of the Course

10)
14)
(Signature of Parent / Guardian)

Date :
per year
p.a.
Ref/ File No. ..
(Signature of the Student)
Principal/ Heads Report / Recommendation

Total No. of Students Strength in the College: . Nos.
It is hereby certified that
a) the particulars given by the student are correct as per the records of the School/College/Institute.
b) the student is/is not receiving financial assistance from any other source.
c) our school/ institute/college is Govt./ Govt. Aided/ Charitable/ Private.
d) our school/ institute/college is affiliated to .................. (Board/University/Council)
e) Total number of students in our college is .during the current year.
f) Our School/Institute/College was established in the year...
Recommended
(Signature of School/ College/ ITI Principal with seal)

Note: Please furnish the required information by filling up the blanks before signing.
Important Instructions
1. Copies of the following certificates issued by the competent authority and duly attested by the Principal /Authorized Professor
or Lecturer should also be submitted with the Application :
i) Income Certificate (income certificate should not be more than 2 year old as on the date of application)
ii) For Physically Challenged - Certificate from a competent authority.
iii) Photocopy of SSLC/SSC Marks Card and of the last exam passed.
iv) For hostellers, a certificate from the Warden or owner of private accommodation duly certified by Principal /
Authorised Professor or Lecturer in the prescribed form downloadable from our website.
v) For widows and Ex-servicemen : a) PPO b) Ex-servicemen Widow I-Card c) Relationship Dependency Certificate
2. Family Income Limits:
(a) (i) Category A & B Certified photocopy of BPL Card or Income Certificate of family income on per annum basis should be
submitted with the application form. Income Certificate not required from orphans who will have to submit death certificate of
his/her parents
(b) For category C, D, & E i) For those in employment - Rs.4.00 Lac per year - Certificate issued by the Employer.
ii) For all others - Rs.2.50 Lac per year - Income Certificate issued by Patwari, BDO, Revenue Officer, any Gazetted Officer, any
Retired IAS, IPS or Class I Central Govt. Officer. For Rajasthan state, since the Govt. of Rajasthan has prohibited the Revenue Officers
from issue of Income Certificates and have authorized self certified Income Certificates duly notarized by the Notary Public with two
responsible witness, such Income Certificates will be accepted from Rajasthan.
In case the Income Certificate is issued in any language other than Hindi or English, the student should also submit a translated copy
in English or Hindi duly certified by the Principal / Authorized Signatory.
4. Downloadable Application form is available on our website www.sitaramjindalfoundation.org
5. A student should apply for scholarship only once in the duration of the course.
6. The student should not be getting any other stipend or scholarship from any other source.
7. Scholarship shall be discontinued after the student crosses 30 years of age.
8. Applications should be sent to the address given below:
(i) For those, located in the following states:
Andhra Pradesh, Andaman & Nicobar Island, Dadra & Nagar Haveli, Daman & Diu, Gujarat, Goa, Karnataka, Kerala, Lakshadeep,
Maharashtra, Puducherry, Tamil Nadu, Telangana.
The Trustee,
Sitaram Jindal Foundation,
Jindal Nagar, Tumkur Road,Bangalore 560 073
(ii) For the States of Assam, Arunachal Pradesh, Bihar, Chhattisgarh, Chandigarh, Delhi, Haryana, Himachal Pradesh, Jharkhand, Jammu &
Kashmir, MadhyaPradesh, Manipur, Meghalaya, Mizoram, Nagaland, Odisha, Punjab, Rajasthan, Sikkim, Tripura, Uttar Pradesh,
Uttarakhand, West Bengal.
The Trustee,
Sitaram Jindal Foundation 11, Green Avenue,
Behind Sector D-3Vasant KunjNew Delhi 110 070
9. Engineering, Medical and MBA students should submit a certificate duly signed by the Head of the Institution that the student got
admission on merit as received from the competent authority and not on payment seat.
10. Scholarships will be given in all Govt., Govt. aided Schools, Colleges/ Institutes and those private schools, Colleges/ institutes
where exorbitant fee is not charged from the students.
11. For 3 years or longer duration courses, applications will not be entertained from final year students.
12. Scholarship will not be given for courses of less than one year duration.
Note:- Only those which use the application forms downloadable free of cost from the Foundation's website will be entertained.
Application forms separately printed (in Printing Presses) will not be entertained.
Caution: Please ensure information and documents furnished are absolutely genuine and correct failing which action will be taken as we
have stringent system of checking and verification by which some persons were caught and punished.

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w.e.f.5.1.

S R JINDAL SCHOLARSHIP SCHEME

(The applicant should enclose documents mentioned under Important Instructions)

Name in Full (CAPITAL LETTERS)

Fathers/ Guardians name

Address for communication

Tel. No Landline (with STD Code)

a) Course & Semester / year in which studying at present

a) Name of school/ college/ institute/ ITI in which presently

Total fees per year

Have you applied previously to us for scholarship, whether

Whether staying in Hostel run by the College/ Institute

Yes/No (Tick () whichever is applicable)

Scholarship amount required

Details of the bank account of the student

S.B. A/c. No.

I hereby certify that the information disclosed by me is true.

I agree to abide by all the Terms and Conditions of the

d) Month & Year of Final Exam at the end of the Course

(Signature of Parent / Guardian)

(Signature of the Student)

Principal/ Heads Report / Recommendation

(Signature of School/ College/ ITI Principal with seal)

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