APPENDIX - 1
GOVERNMENT OF ORISSA
C.D. & R.R. DEPARTMENT
SCHOLARSHIP FOR THE DISABLED
Application form for fresh scholarship
Application must the Collector of the concerned district not later than
PART I
( To be filled in by the candidate )
1. Nature of physical handicap :
2. Name in full : Shri/ Smt./ Km.
(In block letter )
3. Postal address to which communication should
Be sent. :
4. (a) Are you a citizen of India ? :
(b) District and State to which you belong :
(c) Whether scheduled Caste/Tribe :
5. Date of birth :
( In Christian era )
6. Name and address of the parents/guardian and Name of the parent/guardian..
Relationship of the guardian with the applicant.
Profession
Address
Relationship of guardian.
.
7. Total monthly income to both the parents/
Guardian .
8. Please sate , if you are earning an income : Yes/No
If yes, please indicate
(i)The source
9. (a) Particulars of all examination passed ( commencing with the middle or equivalent examination.
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Name of Year Subjects Name of Name of
Examination taken Institution Board /University
(1) (2) (3) (4) (5)
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(b) Percentage of marks obtained in the last
examination passed (Enclose Mark list).
( In the case of examination in music , indicate
division obtained ).
10. Have you ever received scholarship under the Yes/No.
Scheme ?
(i) Class in which scholarship last awarded ..
(ii) Period for which scholarship was paid ..
(iii) Sanction / Reference No.
11. please state whether you have undergone any
training course at any training center for adult
blind/ deaf approved by the Centre / State
Government.
12. (i) Course of study for which scholarship is now
desired, mention class.
(ii) Date of commencement of the course
(iii) Approximate date of termination of the
Course.
(iv) Exact date of joining the present standard /
Class in the course during the current academic
Year.
13. For blind ---
Have you engaged a reader?
If yes, please indicate -- .
(i) Amount paid per month .
(ii) Date of engagement .
14. Documents attached
(i)
(ii)
(iii) ..
(iv) ..
(v) ..
I hereby declare-
(i) that I shall not accept emoluments, scholarship , stipend , or any other financial assistance or grant in any other form whatsoever , except examination from tuition fees, from any other source during the tenure of the Government of India Scholarship , If awarded to me under the above Scheme.
OR
That I am in receipt of assistance to the tune of Rs. ____________ from _________________ and in the event of award of scholarship , I undertake to refund it from the month the scholarship is payable to me , to the source from where I have received it, and that during the tenure of scholarship , if awarded I shall not received any other financial assistance , emoluments, Scholarship , stipend or any grant in any form whatsoever except the exemption from payment of fees.
(ii) that the statements made in the application are true to the best of my knowledge and belief and that no material information having a bearing on selection has been concealed or withheld.
Counter signature of Signature of the Candidate
Gazetted Officer of
Central / State Govt. /
M.P./ M.L.A. / Magistrate/
Head of the Institution . Counter Signature
of the guardian , in case
Place : the candidate is minor
Date :
( To be filled by the Head of Institution )
1. (a) Is the candidate enjoying free board and / or,
loading facility or any other concession in
kind from any other source ?
(b) If so, indicate the monthly amount
Equivalent to the concession.
2. Is the candidate residing in an hostel attached
to School/ College / Establishment ? If so, date
from which residing .
3. (a) details of the nearest branch of Reserve
Bank of India / or State Bank of India or a
subsidiary Bank affiliated to the State Bank
of India , where Government business is
transacted.
(b) The designation of an officer in whose
favour Demand Draft may be remitted.
(i) (a) Is the candidate using any prosthetic
appliance (s) used.
(b) If so, please indicate the nature of
appliance (s) used.
(ii) (a) Is the candidate using special transport
to and from the Institution ?
(b) If so , please indicate clearly the mode
of transport and the approximate
distance traveled daily.
Has the candidate engaged a Reader ?
If so , the monthly amount paid to him /
Her and the date from which engaged.
Certified that
(i) The information given by the applicant in Part I has been checked and found , correct .
(ii) This institution is affiliated to the University of .and / or is recognized by the Government of and the course of study / training is recognized by that University/ Government.
No. Signature of the Head of the
Institution.
Name
( In block letters)
Place : Designation .
Address
Date : PIN
(Seal of the Head of the Institution)