This document appears to be an application form for a minority scholarship scheme in Maharashtra, India. It requests personal details of the applicant like name, gender, date of birth, nationality, religion, parents' names. It also asks for education qualifications, annual family income, bank account details, details of the course and institution where admitted, documents to be enclosed like income certificate, domicile proof, fee receipt. The applicant must declare that they will abide by scholarship terms and the information provided is correct. The form is to be verified and certified by the head of the educational institution.

1. YES /NO
e. Nationality: Indian
P I N
-
i. Gender (M-Male/F-Female)
/ / ( D D / M M / Y Y Y Y )
(Muslim/Christian/Parsi/Buddhist/Jain/Sikh)
3. Total Annual Course fee in Rs. (Do not include refundable deposits)
Tution Fees Dev. Fees Other Fees Total
a. Name of the Bank :
b. Full Address
P I N
c. Branch Code d. A.c No
e. IFSC code of the Bank Branch
5. Annual Income of Parent / Guardian of the student : Rs. ___________________________
2
1
Minorities Development Department
Year of PassingUniversity / Board Institution / Council
of Examination
Percentage of marks
HSC
g. Tel. No. (With STD)
(Specimen form of declaration of annual income and minority status on Rs. 10/- non judicial stamp paper/court fee is given at
Annexure I which is to be signed by the studnet and parent /Guardian of the student. In case parent / guardian are
employed, income certificate from the employer may also be enclosed)
c. Mothers' Name
( As appeared in the SSC Marksheet )
b. Fathers' / Husbands' Name
Examination Passed
d. Domicile State :
2. Qualification Details ( SSC Onward)
f. Address for
correspondence
k. Religion
j. Date of Birth
h. E-Mail
GOVERNMENT OF MAHARASHTRA
Application Form for Minority Scholarship Scheme for All courses after H.S.C.(Arts,Commerce,Science,etc.)
For Office Use Only
SL. No. of Application Year Course
Recommended for Scholarship ?
a. Full Name:
3
4
4. Details of Bank account of Students
1. Personal Details
Total in words : Rs. ______________________________________________________________________________
FRESH / RENEWAL
SSC
SN
Paste Latest Passport Size Color
Photo with Signature. Do not
Staple.
2012-13
1 / 2

2. 6. a.Course Name : b. Year of Study :
a.
b. Institute Address :
P I N
c. Telephone No. d. Fax No.
e. Email Address :
f. Is the college / institution recognized. ( Yes / No)
g.
h. Name of University / Board is it affiliated :
8. Documents to be enclosed with the application
i) Attested certificates of educational qualification as filled up in para 2.
9. Declaration
a
b
c
Date :
Place :
Name (
Date :
Place : Signature of the Head of Institution /
7. Name of the College / Institution where candidate has admitted :
I undertake, if it is found 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.
Institute Name :
ii) Declaration of Family Income & Minority Community Status - affidavit on Rs. 10/- non-judicial stamp paper
/court fee and income certificate from the employer, if any
If yes the name of authority which has recognised the institutions :
College with official seal.
Signature of Candidate
I shall abide by the terms and conditions for sanction of Scholarship for Minority Students for pursuing Technical &
Professional Studies
( Proforma is filled by the Institute / College Head with official seal)
It is certified that the information filled above by Shri / Smt. / Kumari _____________________________________ S/O.
D/O, W/O Shri ___________________________ ____________________ who is admitted in course ______________
for the academic year-2012-13 in college is correct.
iii) Proof of permanent residence ( Domicile Certificate / Ration Card/ Driving License / Electricity Bill/ Indian
Passport/ Election ID/ Telephone Bill/ etc)
10. Verification of information to be furnished by the Head of Instituion / College :
iv)Advance Receipt of Payment
__________________________________)
I hereby declare that the information given above is correct.
v) Xerox copy of Candidate's bank account passbook.
2012-13
2 / 2