APPLICTION FORM

Pre-Matric Scholarship to OTHER BACKWARD CLASSES(OBC) Students Studying in Class I to X (2011-12) Eligible students are advised to submit their application in the prescribed format to their respective school Heads along with the following documents.
(i) One copy of the passport size photograph with signatures of the student thereon (ii) One attested copy of mark sheet of last examination passed. (in case of Class V to IX) (iii) Attested copy of Caste Certificate of student should be issued by the S.D.M. of Govt. of NCT of Delhi. (iv) Self declaration of family income by parent/guardian (as per prescribed format) duly completed. (v) Hosteller Certificate (if any). (vi) ECS Performa, duly completed.

APPLICATION FORM:
Name of the student _________________________________________________________ Date Of Birth(DD/MM/YYYY) ________________________________________________ Name of Father/guardian _____________________________________________________ Residential Address_____________________________________________________ Phone(if any) _____________________________________________________

Class in which he/she studying ________________________________________________ Yearly family income _______________________________________________________ Whether passed the last examination_________________________________________________ Hosteller/Day Scholarship _____________________________________________________

Certified that the information given above is true to the best of my knowledge & belief.

Date: Signature of the student

Performa of Consolidated Statement by School (I to X) List of the students eligible and recommended for Pre- Matric Scholarship to OBC students (2011-12) For use of School only
1. Name & address of the School_________________________________________________ 2. Name of the Scheme: - Pre Matric Scholarship for OBC Students (2011-12) 3. E-mail Address of the School(if any) __________________________________________

S.No.

Name Date of Birth. Fathers/Guardians of Student Name 2 3 4

Present Class

Weather passed the previous examination 6

Amount of Scholarship 7

Yearly family income 8

Hostellers/ Day Scholar(if any) 9

Remarks (if any) 10

I herby declare that the particular given above are correct and complete. 1. Certified that the above particulars have been checked with the office record and found correct. 2. Certified that no eligible student studying in the school/Institute is left out for grant of Scholarship and this list may be treated as final. 3. Certified that these students belonging to OBC Community have not been recommended for grant of Scholarship from any other sources. 4. Certified that the OBC certificate in respect of all the students have been issued by the competent authority/Dy. Commissioner Five Years old residence proof in Delhi i.e. Ration Card/Epic.

5. Certified that the Scholarship or the stipend holders named above have been regular in attendance and have confirmed to the rules under which their scholarship or their stipends are granted. 6. Certified that the eligibility of the student have been rechecked. ECS details in requisite Performa are attached. 7. Certified

that all the requisite information/ documents such as application forms. Caste certificate, mark-sheet, self declaration of family income. Etc. are kept on school record.

8.Certified that all the eligible students have been informed about the scheme and the scheme has been Displayed on the prominent.

Signature with seal of the

Principal/Head of the Institution

SELF DECLARATION OF FAMILY INCOME

I,.. (Father/Mother/Guardian) of.....................................(Name of Student)who is studying Class ..Sectionin the School .hereby declare that my annual Income from all sources is Rs.. in word If at any stage, it is found that the information given by me is false/not true, all benefits given to the student under welfare schemes could be withdrawn and legal action as deemed fit, may be taken against me or my ward.

Date: Place: Signature (Father/Mother/Guardian) Residential Address

ELECTRONIC CLEARING SERVICE

(CREDIT CLEARING) (For the purpose of various scholarship payment paid by the Deptt. Of SC/ST/OBC/Min. through E.C.S. ) Submit in duplicate. School particulars 1. Name of the School (along with full postal address & PIN code) 2. SCHOOL Code No.: 3. SCHOOL Telephone No. :. 4. SCHOOL E-mail ID. :... Particulars of Bank Account (Please attach a photo copy of cheque) 5. Bank A/c operated by (Whether Principal/DDO may be specified): 6. Bank Name: 7 Branch Address:.. 8 Bank Telephone No.:. 9 M.I.C.R. (9 digit number):.. 10. Bank A/c type (Saving/Current): 11. Bank A/c Number:..

Signature of the Bank account operator with official seal

Dated:. .