DIRECTORATE OF HIGHER EDUCATION GOA EDUCATION DEVELOPMENT CORPORATION

GOVERNMENT OF GOA ( A GOVERNMENT OF GOA UNDERTAKING)

APPLICATION FORM FOR FINANCIAL ASSISTANCE FOR HIGHER

EDUCATION/TECHNICAL EDUCATION UNDER SANT SOHIROBANATH AMBIYE
DNYANVRUDDHI SHISHYAVRUTTI
(BURSARY SCHEME)

Affix a recent
Application. No.______________ Academic Year: _________________ passport size
photograph
A] Personal Profile:
1. Name of the student: ________________________________________________
2. Address for correspondence: _____________________________________________________________
3. City/ Village: __________________ Taluka: ___________________ Constituency: ________________
District: North/South State: Goa Pin-code: ___________________
Gender: Male/ Female/ Others Category: Gen/SC/ST/OBC/Others
Date of Birth: _________________
4. Mobile (Primary): ______________________ Mobile (Secondary): ______________________
5. E-mail ID: _____________________________ Aadhaar Card No.: ____________________________

B] Institution & Course details

Name of College/Institution/University: ___________________________________________________
Year of study: ____________________ Specialization: _________________________________________
Name of the Course/ Programme: _________________________________________________________

C] Academic Profile:

Educational Year of Maximum Marks/ Total Marks/ SGPA/ Percentage/

Qualifications passing SGPA/ SPI SPI Obtained CGPA/ CPI
Std. X
Std. XII
First Year (Sem I)
First Year (Sem II)
Second Year (Sem III)
Second Year (Sem IV)
Third Year (Sem V)
Third Year (Sem VI)
Fourth Year (Sem VII)
Fourth Year (Sem VIII)
PG – Part – I
PG – Part - II

D] Details of any other Government scheme availed:

(a) Name of the Government scheme through which Financial Assistance is availed:
_____________________________________________________________________________________________
(b) Amount of Financial Assistance Availed: ___________________
(*The benefits under this Bursary Scheme shall be available only for those applicants who are
not in receipt of any financial benefits under any other scheme of Government).

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E] Details of Course Fees:

1. Total Course Fees of current academic year: ____________________________

InfoTech/ Total
Text Books/
Tuition Uni. Reg. Library Laboratory/ IT Lab/ Gym Practical Eligible
Reference
Fees Fees Fees Lab Fees IT Fees Fees Fees Fees
Books Charges
(A) (B) (C) (D) (D) (E) (F) (Total
(G)
A to G)

2. Whether the course should be located in Goa and is recognized by AICTE/ Govt. of Goa/
Govt. of India/ Goa University and/or recognized by Directorate of Higher Education/
/Directorate of Technical Education or any other recognizing authority approved by
Government of India or Government of Goa:

__________________________________________________________________________________________

F) Details of parents:

Name of Father and Name of Institution/ Designation Annual Contact/

Mother/ Guardian Company/ Office where /Profession Income Mobile No.
(Mr./ Mrs./ Late) they are working &
address of Business
1.

2.
Total Annual Family Income

Total Annual Family Income from All Sources during preceding financial year:

_____________________________________

(The parents/ guardian is required to submit an affidavit on Rs.100/- stamp paper that
outlines their income details along with the reasons why an Official Income Certificate/ Income
Tax Returns could not be obtained.).

G] BANK DETAILS of the applicant:

SB Account No. __________________________________ SB Account Type: _________________________

Name of the Bank: __________________________________________________________________________

Branch Name: ______________________________________________________________________________

Branch Code: _______________________

IFSC Code: _______________________ MICR Code: _______________________

IS Bank Account seeded by UID No. (Aadhaar Card No.): YES/NO. (Confirm with Bank)

PLEASE NOTE BANK ACCOUNT NEEDS TO BE SEEDED WITH AADHAR CARD No.

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UNDERTAKING

I, Mr./Miss.______________________________________________, hereby, undertake that I

have made myself aware of the terms and conditions of the Goa Government Scheme for
financial assistance for higher education/technical education under SANT SOHIROBANATH
AMBIYE DNYANVRUDDHI SHISHYAVRUTTI (BURSARY SCHEME) and I promise to abide by
them.
I further state that the above information given herein is true to the best of my
knowledge and belief. I have not suppressed any relevant information in respect of my
application. In the event of any information furnished by me herein, is found to be false or
incorrect and/or in the event of any suppression of relevant/ necessary data proved against
me, I have noted that I would be disqualified from the Scheme and the amount disbursed to me
shall become repayable immediately along with penal interest if any.
I further declare that I am not availing any Financial Assistance from the Government
under any other scheme through the institution.
I, Mr./Miss. _________________________________________ Bursary Application Number
__________________ holder of Aadhaar Card Number ______________________________ hereby give
my consent to Goa Education Development Corporation for using my Aadhaar number to establish and
authenticate my identity under Bursary Scheme for purposes mentioned below: Collecting, sharing,
storing, preserving information, maintaining records and using the information and authentication/
verification/ identification records as may be permitted as per applicable law: (a) enabling my account for
Aadhaar enabled Payment Services (AEPS); (b) as well as for regulatory and legal reporting and filling
and/or (c) where required under applicable law.

Dated: Signature of the Applicant

Name: _________________________________

N.B. Please attach certified photocopies of all the relevant documents:

CHECK LIST
(Please tick whichever document is enclosed)

a All relevant Mark sheets from Xth Std.

b Total Family Income from all sources (Income Certificate) issued by
Competent Authority.
c Proof of Admission to the course/ programme and bonafide student
Certificate issued by the Head of Institution.
d Duly certified Fee Structure by the head of Institute where admission is
sought.
e Fee Receipts issued by the institutions for the current academic year.
f Caste Certificate if any.
g Aadhar Card of Student.
h Cancelled Cheque / Bank Pass Book Copy having NEFT Details

** PS: For any Further queries kindly contact Bursary Section on 0832-2411187/94

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H] UNDERTAKING FROM THE PRINCIPAL/HEAD OF THE INSTITUTION

The details as furnished by the applicant in the above application are verified and found
to be correct. It is further verified that the applicant is a bonafide student of this institution
studying in ___________________ for the academic year ___________ with specialization in
_______________________and is not in receipt of any other financial benefit/scholarship of the
Government through this institute.

In view of above the application is recommended for grant of Financial Assistance. If any
of the information is found to be in-correct then the College may be held responsible and
recoveries effectuated along with penal interest if any.

The above details are personally verified by me and are true to the best of my knowledge.
The student is not availing any financial assistance from the Government through this
institution.

College Head of the Institution/Principal

seal

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Guidelines for submission of form.

1. Download and print the application form from www.gedc-goa.org.

2. Fill the form.
3. Attach all the relevant documents.
4. Separate form needs to be filled for each year.
5. Submit the duly filled form to GEDC office within the stipulated time period.

Office address:
Goa Education Development Corporation.
Ground Floor, New SCERT Building,
Alto Porvorim,
Goa. 403521.

Email: [email protected]
Phone: 0832 2411187/94.

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