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265/68 Billouchpura , Takiya Jangli Shah
Lucknow
LUCKNOW
Uttar Pradesh
226003

MINORITY WELFARE - POST MATRIC SCHOLARSHIP SYSTEM

Fresh

STUDENT APPLICATION

 

 

For official use only

Sl No of application

Year

Course

Whether approved

 

 

 

 

 

 

 

 

Student ID: T2013uppms198914

Admission 35926

1.Student Name

:

HUDA FATIMA

2.Father's name/Husband's name

 

:Mohd Gaus

3.Mother's name

 

: Shahzadi

4.Mobile No

:

9889866869

5.E-Mail

:

 

6. Domicile State/UT (State/UT which the

 

Uttar Pradesh

student belongs to)

:

 

7. Address for correspondence:

 

 

Affix a self attested passport size photograph

House No. & Street Detail

265/68 Billouchpura , Takiya Jangli Shah

 

 

 

City/Town/ Village & P.O.

Lucknow

 

 

 

District

LUCKNOW

 

 

 

State

Uttar Pradesh

 

 

 

Pincode

226003

 

 

 

8. Permanent address(please enclose residential certificate from concerned state government authority):

House No. & Street Detail

City/Town/ Village & P.O.

District

State

Pincode

9. Date of birth (Please enclose certificate) :

26-Jan-1996

10.

Whether male or female

:

Female

11.

Religion

:

Muslim

12.

Nationality

:

Indian

13.Aadhar No

 

:

Printed Date: 26-Sep-13

Page 1 of 7

 

13. Details of educational qualifications from matriculation/SSLC/SSC onwards (Please enclose certificates attested by a gazetted officer):

Last

University/Board/College (or)

 

 

Year of

Percenta

Division

Qualifying

School/Council of Examination

Main

Passing

ge marks

/Class/

Exam

 

 

Subjects

 

 

Grade

SSLC

 

 

 

2012

68.0000

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

Name of the course:

B.A( BACHELOR IN BUSINESS ADMIN )

 

 

 

 

 

 

 

Duration of course

3

 

 

 

 

 

 

 

 

 

Academic year

2013-2014

 

 

 

 

 

 

 

 

 

 

Hosteller

 

N

 

 

 

 

 

 

 

 

 

 

 

15.Basis of admission in professional/technical course (whether on the basis of qualifying competitive examination or on other grounds. Please give details):

16.Details of college/school:

(i) Name of the college/School where

Shia Inter College Lucknow

admitted:

(ii) Address of college/school: 2,SITAPUR ROAD ,KHADRA ,LUCKNOW ,226020

(iii)Telephone no: 9411831533

(iv)Fax no:

(v)E-mail address:

(vi)Is the college/school recognized. If so the name of authority which has recognized the College(or)School:

(vii)To which university is it affiliated/does it have deemed university status :

UTTAR PRADESH MADYAMIK SHIKSHA PARISHAD ALLAHABAD

Printed Date: 26-Sep-13

Page 2 of 7

 

17. For renewal of scholarship:

Name of examination passed

Year

Marks Obtained

Full marks

% of marks

 

 

 

 

 

 

 

 

 

 

18. Total Annual course fee: 537.00

(Break up of course fee such as tuition fee, library fee, examination fee etc. other than refundable deposits):

Sl.No.

Item

Annual fee

 

 

 

 

 

1.

Tuition Fee

212.00

 

 

 

2

Admission Fee

325.00

 

 

 

 

Total

537.00

 

 

 

19. Details of bank account of student:

Name of the payee (as in the bank accounts)

Name of the Bank

BANK OF BARODA

 

 

 

 

Full Address

NAKHAS

 

 

 

Bank

District

 

 

 

State

 

Branch

 

 

 

 

 

Pin code

 

 

 

 

Branch Code number

 

 

 

Bank Account Number

35150100004013

 

 

Bank Account Number in words

 

 

 

Type of bank Account(Saving/Current)

 

 

 

IFSC code of the Bank

BARB01NAKHA

 

 

Mode of Electronic transfer available in the Bank –

 

ECS/RTGS/NEFT/CBS/code number (if any);-

 

20. Annual Income of parent/guardian of the student: Rs. 36000

(specimen form of declaration of annual income is given at Annexure which is to be signed by the parent/guardian of the student and enclosed alongwith the application. In case parent/guardian are employed, income certificate from the employer may also be enclosed)

Printed Date: 26-Sep-13

Page 3 of 7

 

21.Documents enclosed with the appplication:

(i)One copy of passport size photograph with signature

(ii)Attested certificates of educational qualification as filled up in para 11.

(iii)Income declaration - affidavit on non-judicial stamp paper and income certificate from the employer

(iv)Proof of permanent residence

(v)Receipt in acknowledgment of scholarship in the previous year duly countersigned by the head

22.Declaration :

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

(ii)I am not availing any other scholarship for this purpose from any other sources.

(iii)I shall abide by the terms and conditions for sanction of the Post-Matric based scholarship.

(iv)I undertake, that if at any stage, it is found to the satisfaction of the sanctioning authority in the Ministry of Minority Affairs 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 liability for such penal action as warranted by law.

Signature of the candidate

Date:

Place:

Printed Date: 26-Sep-13

Page 4 of 7

 

21.Verification/information to be furnished by the Head of institution/college:

It is certified that the information filled in the above mentioned columns by Shri/Smt/Kumari

HUDA FATIMA S/O, D/O Shri Mohd Gaus who is admitted in B.A( BACHELOR IN BUSINESS ADMIN ),I year for the academic session 2013-2014 in Shia Inter College Lucknow college is correct. He/she is a hosteler/day scholar of the college.

For Renewal of scholarship:

Details of bank account of institution/college (For deposit of course fee):

(i)Name of the payee (as in the bank accounts) :Principal Shia Inter College

(ii)Name of the Bank : UNION BANK OF INDIA

(iii)Bank Branch (Full address) :

State

District

Pin

(iv)Branch Code number :

(v)Bank Account Number : 540802010508326

(in words_________________________________________________________)

(vi)Type of bank Account : S

(vii)IFSC code of the Bank : UBIN0554081

(viii)Mode of Electronic transfer available in the Bank –

ECS/RTGS/NEFT/CBS/code number (if any);-

Signature of head of the institution / college

With official seal

Date:

Place:

Printed Date: 26-Sep-13

Page 5 of 7

 

Eligibility criteria

(i)Students, who have got admission in a recognized college to pursue technical/professional

courses, on the basis of a competitive examination

ii) Students, who have got admission in a recognized college to pursue technical/professional courses, without facing any competitive examination, will also be eligible for scholarship.

However, such students should have not less than 50% marks at higher secondary/graduation level. Selection of these students will be done strictly of merit.

iii)A scholarship holder under this scheme will not avail any other scholarship/stipend for pursuing the course.

iv)The annual family income of the beneficiary/parent or guardian of the beneficiary should not

exceed Rs.2 lakh per annum from all sources.

v) A student residing in a particular State/UT will be entitled for scholarship under the quota of that State/UT only irrespective of his place of study.

How to Apply

Applications in the prescribed format may be submitted to the Secretary of the, deptt. of the concerned State Govt/UT administration, dealing with minority welfare, through the institutions where the students are pursuing technical/professional courses. The student must submit their applications to the state which he/she belongs to and not to the state where the institution where he/she is studying, is located.

Printed Date: 26-Sep-13

Page 6 of 7

 

Annexure

DECLARATION OF FAMILY INCOME

I Mohd Gaus (Father /Mother /Guardian) of HUDA FATIMA (Name of student) who is studying in B.A( BACHELOR IN BUSINESS ADMIN ) I year hereby declare that my annual income from all sources is Rs./ 36000.00 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 scehme of Post-Matric scholarship based to the student belonging to minority communities could be with dran and legal action as deemed fit, may be taken against me or my ward.

 

Signature

 

Residential Address

265/68

Billouchpura , Takiya Jangli Shah

Date:

Lucknow

 

(Father/Mother/Guardian)

LUCKNOW

 

Uttar Pradesh

 

226003

[This is a draft format which the State government/UT administration may modify/amend to suit legal requirements]

Address as per the advertisement of the

District Minority welfare Officer, Officers Care of

District Magistrate

Concerning District. Follow the below Link for Complete Postal Address www.minoritywelfare.up.nic.i n and then DMWOOffice.htm

Printed Date: 26-Sep-13

Page 7 of 7