This document contains an application form for the Banishree scholarship scheme for physically challenged students in India. The form collects information such as the applicant's name, address, disability details, family income, previous receipt of other scholarships, details of current class and institution, and whether a reader is required. The applicant and head of institution must fill their sections and certify the information. The sanctioning authority then verifies the form and sanctions the appropriate scholarship amount if eligible.

1. ANNEXuRE -I
fippLicaTION FORM
(BANISHREE-ASchemedofScho]arshipforPhysica]]yCha]]engedStudent)
(To be filled by the Candidates)
For the year.................................
1, Name in Full
(In Block Letter) ...................................................................... „ ................... „ ........................
2. Address ........................ „ ........................... „ ...............,........ „...„ ..............-.............................
VI«a§e/Vvard.....................................................P.S.................................„.„..........................
G.P........................................"...............................-.........................................-...................
BIockINAC"unicipality..................................„........................„.............„......„.....................
District.........................................................:...................-............................-.....................
3. Category of Disabjljty
(Pl. Tick whichever is applicable)(V)
4. Are you a citizen of India ? (Pl. Tick) (/)
5. Whether Scheduled Caste / Tribe / OBC / General
(please mention)
6. Male / Female (please mention)
7. Date of Birth (Please mention)
OH / HH / VH / MR / CP
Yes / No
8.NameandAddressoftheFather/MothertGuardian..........................................................
•........-.................................................................-.......-.......-.-.....,..........`..".'...".....p.....-'
•..........................................................................................................'.................I.........I.......
9. (a) Relationship with the Guardian (if applicable)
(a) Total monthly income of the Parents / Guardian
10. Nature of Scholarship (Please Tick) (V/)
11. (a) Have you ever received Scholarshjp under any other :
Scheme, (Please Tick) (V)
(Fresh / Renewal}
Yes / No

2. J/ i' `,cS "iJ:.c,.I->
t. .`-.:z..`:, ;n `/hich you received the Scholarship
(:I,` ->.3i:ic! far which you received such scholarship :
12. Mention
(a) Class for which I am applying for Scholarship
(b) Academic year of such class
© Date on which you got admission
€'
13. (a) lfyou arevisually challenged student, indicate if you : Yes/Nc
have engaged a reader ? (Please Tick)(`/)
i`'>`, lf you are Orthopaedically Handicapped students :
!~,`:;i`g 75% and above disability indicate the mode of
trar.si:ort.
14. Documents Attached :
(I) Income certificate/copyofBPLcard (PI. lick)(/) : Yes/ No
(ii) D4sability certificate (Pl. Tick) (/) Yes / No
(iii) Mark-sheet of last Exam. Passed (PI. lick) (`/) Yes / No
CtvJ @artyt` Wc_ No tt;e¥oi
I declare that I have not received (not receiving) an}p' Other financial assistance
from State / Central Govt.
Signati.I-;3 :`.r trc. Student
Da?£ ,
Pla'=e :

3. (To be filled by Head of School / Colleges / Educational Institutions)
I Certify that :
* The information furnished b; the candidates (name ........................ „.`..... „ ...................... „
.......,................................................. ) have been verified and found correct
* The School / Institutions in. which the candidate is studying is
Govemmenvrecognised private schoomnstitutions (Pl. Tick){^:~;I `^t which ever is applicable
* The application is recommended.
Signature of the Head of the Schcol /Institution
Name........................................................I-......
(ln Block letter)
Address......................„.................„...................
..............................-........................-.....,,,,,,,......
•.................................................................,........
•...........................I.....................................,,,,,....
Date................................Place..........................
( To be filled in by Sanctioning Authority )
I have verified the jnformations as furnished by head of School / Institution. I hereby santion
Rs .................................... towards Scholarship and Rs ................................................. towards
Reader's allowance/mobility support, thus totaling to Rs ..........................................................
Sanction Order No ..................... „ .............. Date ......................................
Signature with Seal of
B.D.O./Sub-Col(ec+.or