Application Form for Scholarship

FOR FOUNDATION USE ONLY

(Not to be filled in by the student)

APPLICATION NO: Category………… Max.Limit ……… No. of Scholarship

Ref. No. : Sanctioned so far ………

1. Name Mr./Miss………………………………………………….. 6. Amount of Scholarship Rs………………….. p.m.

………………………………………………………( ) (Rupees……………………………………………. per month)

2. Studying in………………………………………………………… 7. Period of Scholarship……………… years……..months

3. Duration of course ……………………. Years………………
4. Last exam. Passed …………………………………( %)

5. Family Income Rs………………… p.a. 1. 2. 3.

Sitaram Jindal Foundation Annexure II

11 Green Avenue, Bhatta Road, Behind Sector D-3, Vasant Kunj, New Delhi - 110 070
Jindal Nagar, Tumkur Road, Bangalore - 560073
Affix Passport
(to be filled in by the student very carefully) Size Photograph
attested by the
Principal with
1) Name in Full …………………………………………………………
Seal
(CAPITAL LETTERS- as per marksheet)

2) Date of Birth : ……………………………… 3) Nationality: ……………………………………….

4) Addresses with Pin Code (a) Present address and : ……………………………………………………………………..
Telephone No. ……………………………………………………………………..
……………………………………………………………………..

(b) Permanent address and : ……………………………………………………………………..

Telephone No. ……………………………………………………………………..
……………………………………………………………………..

5) Father’s/ Guardian’s name with phone number and : ……………………………………………………………………..

email-id

6) Are you physically handicapped or Ward/Widow of Ex- : ……………………………………………………………………..

Serviceman (State Clearly)

7) Occupation of Father/ Guardian & annual income of : ……………………………………………………………………..

entire family from all sources Rs.……………………………………………………….…. p.a.

8) Particulars of last examination passed : ……………………………………………………………………..

Total marks & Percentage of marks obtained : …………………………..……% ………………………………

9) Class/Trade in which studying at present : ……………………………………………………………………..

Whether regular or part time or by correspondence ………………(Regular/ Part Time/Correspondence)

10) Name, address and e-mail id of School/ College/ : …………………………………………………………………….

Institute : ……………………………………………………………….……

11) Duration of the Course : ………….. Years

12) Month & Year of Final Exam of Course : ………. Month ……… Year

13) Total annual fees : Rs.………………………………………. p.a.

14) Whether staying in Hostel (only ITI & College Students) : Yes/No……………………………………………………………
(If yes, what are the charges incurred per month) : Rs.………………………………………. p.m.

P.T.O.
 15) Are you getting any stipend/ freeship/ scholarship : …………………………………………………………..Yes/No
from any other source.
If so mention source and amount. : Rs.…………………………………………………………. p.m.

16) Have you applied previously to us for scholarship, Yes/ No Ref/ File No. …………..
whether it was sanctioned, if so, reference/file No.
17) Scholarship amount required : Rs.…………………………………………………………. p.m.

18) Name and location of Bank branch along with full : ……………………………………………………………………
details of the account of the Student. ……………………………………………………………………

I hereby certify that the information disclosed by me is true. I agree to abide by the Terms and Conditions of the
Foundation prevailing from time to time.

…………………………………………… ………………………………………
(Signature of Father/ Guardian) (Signature of the Student)
Place :
Date :

Documents to be attached :
For BPL Students : Photocopy of BPL Card duly attested by the Principal and copy ofMarks Card of previous
(School Girls) & (College Boys & Girls) Examination

For ITI students : In case student stays in hostel, submit payment receipts alongwith original Hostel Certificate/
Letter from Warden duly attested by the Head of the Institution where studying.

For College Students : 1) Photocopy of income certificate issued by competent authority duly attested by the Principal/
(both graduate and post graduate) Head as per ANNEXURE-IV.
2) Photocopy of the marks sheet of class X, XII and last qualifying examination passed duly
attested by the Principal/ Head.
3) In case student stays in hostel, submit payment receipts alongwith original Hostel Certificate/
Letter from Warden duly attested by the Head of the Institution where studying.

Additional documents to be attached in case of :

(i) BPL student : Photocopy of BPL Card duly attested by the Principal/ Head.

(ii) Physically Handicapped Students : Photocopy of the disability certificate issued by the competent authority duly attested by the
Principal/ Head.

(iii) Widows and wards of Ex-servicemen :

(a) Attested photocopy of discharge book and PPO of the ex-serviceman
(b) Attested copy of ex-serviceman/ widow identity card issued by Rajya/ Zila Sanik Board
(c) Attested copy of relationship/ dependency certificate from OIC records.

Please refer our website www.srjf.org for list of ITI trades, graduation & post graduation courses eligible and other conditions before filling up
the form.
(Attestation of the photograph by the Principal with Seal is must)

Principal/ Head’s Report

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 bears a good moral character.
c) the student is/is not receiving financial assistance from any other source.
d) the student is/is not physically handicapped/disadvantaged.
e) our school/ institute/ college is Govt./ Govt. Aided or Private …………………………….. (State clearly)
f) our school/ institute/ college is affiliated to ………………………………………………. Board/ University/Council
g) number of students in school (class IX to XII)/ institute/ college is ………………………………………..Nos.
h) the foundation shall be informed, if the student leaves studies.

It is further recommended that the student may be awarded a scholarship f Rs………………… p.m. till
……………………………………….. (State month & year of last final exam of the course).

Signature of School/ College/ ITI Principal with seal

Date :