Scribd
Upload
1K views6 pages

Form No GJS1

The document contains an application form for the LIC Golden Jubilee Scholarship. [1] It requests information such as the applicant's personal details, family details, educational qualifications, bank account details, annual income, and documents to submit. [2] The head of the applicant's school/college is also required to verify and fill Part II of the form which includes details of the educational institution and a confirmation of the applicant's enrollment status. [3] The applicant and their parent/guardian must also declare their annual income and sign a notarized affidavit confirming the income details provided in the application.

Uploaded by

NIKHIL SWAMY B C
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
1K views6 pages

Form No GJS1

The document contains an application form for the LIC Golden Jubilee Scholarship. [1] It requests information such as the applicant's personal details, family details, educational qualifications, bank account details, annual income, and documents to submit. [2] The head of the applicant's school/college is also required to verify and fill Part II of the form which includes details of the educational institution and a confirmation of the applicant's enrollment status. [3] The applicant and their parent/guardian must also declare their annual income and sign a notarized affidavit confirming the income details provided in the application.

Uploaded by

NIKHIL SWAMY B C
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 6

Form no GJS1

FOR OFFICIAL USE ONLY


Sl. No. of Year Course Whether
application approved

FORMAT OF APPLICATION
Affix a recent
self attested
Part – I [To be filled up by applicant.] passport size
photograph

1. Full name (in block letters)


Surname
First Name
Middle Name

2. Father’s name:

3. Mother’s name:

4. State/UT of domicile

5 .Address for correspondence:

Name
House no.
Mohalla/Street
City/Village/
PO
District
State
Pin Code
Telephone no.
Mobile no
e-mail –id

6. Date of birth (Please enclose certificate)

D D M M Y Y Y Y

7. Whether male or female:

8. Nationality:
9. Religion:

10. Category (Please tick appropriate box)

General OBC SC ST OTHERS

11. Details of educational qualifications from matriculation/SSLC/SSC


onwards (Please enclose copies of certificates attested by a Gazetted
officer/Class-I Officer of LIC )

Examination University/Board/ Main Year of Percentage Division/


passed Institute/Council subjects passing marks Class/
of Examination Grade

12. Details of course for which scholarship is being sought:

i Name of class/course
ii Duration of class/course
iii Academic year
iv Class /course last attended / academic year
v Total Marks obtained and percentage in last
examination

13. Details of school/college/institute, including residential ones:


(i) Name of the school/college/institute where admitted:

(ii) Address of school/college/institute:

14. Total Annual course fee: Rs (In Words & Figures)

15. Whether you are receiving any scholarship: Yes /No

If Yes, please give following details:

i) Name of the scholarship scheme


ii) Amount of scholarship
16. Details of bank account of student:
(i) Name of the payee (as in the bank accounts) _________________________
(ii) Name of the Bank

(iii)Full address of the Bank Branch _____________________________


_____________________________
_____________________________
State: ___________ Pin: ___________
(iv) Bank Account Number

(v) IFS Code of the Branch

(If the candidate is selected, this code is required to transfer scholarship


amount to the candidate’s above account through NEFT. Hence kindly confirm
with the Bank and provide correct details.)

17. Earning Member of the Family : Father/Mother/Others (If others, pl.


specify)
(Please mark √ against appropriate box.

Father
Mother
Others (Please Specify)

18. Annual Income of parents/guardian of the student: Rs.(In Words &


Figures )
________________________________________________________________

(Specimen form of declaration of annual income is given at Appendix to this


application form which is to be signed by the parents/guardian of the student and
enclosed along with the application. In case parents/guardian are employed, income
certificate from the employer should be enclosed).

19. Particulars of death in immediate family due to Covid 19:


Name of Deceased Person Relationship with Scholar Date of Death (Death
Certificate to be
submitted)
20 . Documents to be enclosed with the application

(i) Self-attested passport size photograph with signature.


(ii) Attested copies of certificates of educational qualifications as mentioned in para
10 above.
(iii) Income declaration – affidavit on non-judicial stamp paper for self employed
parents /guardian or income certificate from the employer for employed
parents/guardian.
(iv) Proof of permanent residence.
(v) Death Certificates of death of immediate family Members due to COVID 19.

21. Declaration:

(i) I hereby declare that the information given above is correct.


(ii) I shall abide by the terms and conditions for sanction of the Scholarship.
(iii) I undertake that if, at any stage, it is found to the satisfaction of the sanctioning
authority that the information given by me is false or if I violate the terms and
conditions of the scholarship, the scholarship sanctioned to me, may be
cancelled and the entire amount of scholarship will be refunded by me or
recovered from me, apart from such penal action as warranted by law.

Date:
Place: Signature of the student
Part–II [to be filled up by the Head of the school/college/institute]

1. Details of school/college/institute including residential ones:

(i) Name of the school/college/institute where admitted:


(ii) Address of school/college/institute:
(iii) Telephone No:
(iv) Fax no:
(v) E-mail address:
(vi) If a private institute, is the school/college/institute recognized? If so, the name
of authority which has recognized it:

2. Verification/information to be furnished by the Head of school/


college/institute:

(i) It is certified that the information filled in the above mentioned columns by
Shri/Kumari________________s/o / d/o Shri ____________________________________
who is admitted in _______________________________course for the academic
session________________in_____________ school /college/institute is correct.

(ii) He/she is a hosteller/day scholar of the school/college/institute.

Or

He/She is staying as paying guest/in a rented accommodation as declared by the


scholar in the application form and is the same in the school records.

(i) He/She is a fresher admitted in the school for academic year _________.

Or

He/She has been promoted from _________ to __________ in the academic year __________.

Signature of Head of the school/college/institute


Date: With official seal
Place:
Appendix to the Application Form
(Specimen)

DECLARATION OF PARENTS’/GUARDIAN’S INCOME

I………………………………………………….……….…… (Parents/Guardian) of
……………………….. ………………………… (Name of Student) who is studying
in…………………………………….. hereby declare that my annual income from all sources
is Rs………./- (in figures) Rupees……………………… ……only (in words). If at any stage,
it is found that the information given by me is false/not true, all benefits given to the
student under the scheme of “LIC Golden Jubilee Scholarship for students belonging
to economically weaker families” could be withdrawn and legal action as deemed fit,
may be taken against me or my ward.

Signature
(Father/Mother/Guardian)

Date:

Residential Address

Note: To be executed on Non-judicial Stamp Paper of the value


applicable in
the state duly notarized (KARNATAKA Rs.20/-)

You might also like