vh)vT) t>#i, didri ngr hv[l) {s>G p\d[S}, (SxN (nyimkn) kc[r), {Ci#ivZ(t ...

vh)vT) t>#i,
didri ngr hv[l) {s>G p\d[S},
(SxN (nyimkn) kc[r),
{Ci#ivZ(t (vBig}
s[lvis.
n>.eD)a[n/a[kiuºT/Ci#ivZ(t/2012-13/ ti. -07-2012.
-: p (r p #i :-
aiY) a[s.a[s.s) tYi a[c.a[c.s). pr)xi ut)N< kyi< bid a¿yis miT[ jnir an&s*(ct
ji(t / an&s&(ct jnji(t tYi aºy ji(tni ai[C) aivkv Grivti (vwiY) aiv[ C[
k[ 2012-2013ni vP< miT[ pi[OT m[T^)k Ci#ivZ(t n)c[ jNiv[l (nymi[ an&sir a#i[n) kc[r) mirft
aipvimi> aivnir hi[y, t[ a>g[ni (nyt kr[l arJ p#iki[ m[Lv) s>p*N< (vgti[ Br)n[ arJ p#iki[
mi[Dimi> mi[Di ti.30-11-2012 s&G)mi> a#i[n) kc[r)a[ mL[ t[ m&jbni[ p\b>G krvi[. arJ p#iki[
ki[l[jni> (vwiY)D}
(SxN (nyimk,
didri ngr hv[l),
s[lvis.

-: Ci#ivZ(t m[Lvvi a>g[ni (nymi[ :-
1. um[dvir {(vwiY)< } s>G p\d[S didri ngr hv[l)ni[ kiym) vtn) hi[vi ji[ea[ an[
t[ bibtni[ mimltdir~), didri ngr hv[l), s[lvisni[ diKli[ l[vi[ / (ptin&>
aYvi {giD) (vwY)AYimi> kim krti km aivS[.
5. aigli vP p\miNp#in) nkl j[iDv) t[mj Ak&l / ki[l[j
l)v)>g sT) Br[l f)n) rs)d ji[Dv).
7. hi[AT[lmi> rh[ti (vwiY)
p\imNp#i ji[Dv>&.
8. vil)ni> r[Sn kiD s>p*N< (vgti[ Br) arJ krvin) rh[S[, aG*r) (vgt
viL) t[mj j$r) p\miNp#ii[ arJ siY[ (bDiN kr[li n hS[ t[i t[mj y[i³y kirN
dSig[ ki[epN jitni p#iÄyvhir kyi< vgr dftr[
arJ srvimi> aivS[ j[n) ni[>G l[v).
10. Gi[rN 11 an[ 12ni> (vwiY)Y) j arJ p#iki[
aipvimi> aivS[, j[ s>p*N< (vgt Br)n[ a[mN[ SiLimi> j aipvini rh[S[.
11. ki[l[jni dr[k (vwiY) aiv[ C[ k[ j[ (vwiY)< j[ t[
ki[l[jmi> a¿yis krti hi[y t[ ki[l[jni> vDin) sh) (skki kr) Aki[lrs)pn&> fi[m<
jmi krivv&>.

nkl rvini:-
{rik[S k&mir gi]>D}
(SxN (nyimk,
didri ngr hv[l),
s[lvis.
1. tmim kc[r)ni> vDiai[ trf jiN miT[.
2. p\m&K~), (jÃli p>city, didri ngr hv[l), s[lvis.
3. srp>c~), tmim g\&p g\im p>city didri ngr hv[l).
4. h[DmiAtri[, tmim mi´y(mk/uµctr mi´y(mk srkir) SiLiai[n[ jiN tYi
(vwiY)

Application Form for Post Matric Scholarship for the Year 2012-13.
Govt of India
DEPARTMENT OF EDUCATION
U.T of Dadra & Nagar Haveli
Silvassa
ANNEXURE –III
Government of India Scheme of Post – Matric Scholarship for Scheduled Caste and
Scheduled Tribe _________________ State / Union Territory.
APPLICATION FORM FOR FRESH SCHOLARSHIP
(To be submitted to Department of Education not later than 30 TH
November,2012 ).
HISTORY SHEET OF APPLICATION FOR THEPOST MATRIC
SCHOLARSHIP TO SC/ST & LIG STUDENTS.
PART – A
( To be filled in by the applicant )
Sr.No Particulars
1. Name in full (Block Letters Shri/Smt/Kum.
only)
2. Father’s/
Husband’s Name
Shri
3. Nationality INDIAN
4. Caste/Tribe
5. Full Address of the
Applicant with Phone No.
Phone No. :-
6. Whether applicant is employed. if yes then give :-
1. Name of Employer
2. Address of Employer
3. Total monthly income
including all allowances
4. Whether the applicant
has to support a family
or not.
5. Whether married or single
6. Total annual income for
year ending 31 st March
2012 from
• Applicants

7.
• Father’s/ Gardian
7. Occupation
Name of the Guardian
Relation with the Applicant
Address of the Guardian
8. Particulars of examination taken commencing with the matriculation or
equivalentexamination (please attach attested copies of certificates / marks sheet.
Any break in educational career should be mentioned in remarks column
9.
indicating also how he /she occupied himself / herself in that period).
Name of
Examination
Year in which
taken
Whether passed or not.
In case of
Last exam. Passed ,
indicate percentage of
marks and Division
Institution and
University /
Board
Remarks
1 2 3 4 5
1.
2.
3.
4.
Whether in receipt of scholarship under this Scheme or any other scheme in
the previous year (If yes, then indicate the below details.)
1. Name of the scheme
2. Course of study for
which scholarship was
given
3. Name of the institution
in which the scholarship
was Awarded
10. Course of study for which
scholarship is now
desired
In which Class studying
this year
Date of joining the class
11.
13.
If residing in the hostel of the institution or a hostel
Name
Date of joining
Address of Hostel
Document attached :
1. Caste / Tribe and
income certificate.
2. Income Declaration

Statement
3. Attested copies of
marks sheet certificate
4. Part ‘B’ of the
application form duly
completed and Signed
by the Head of
Institution
5. Ration Card copy.
DECLARATION :
I / We hereby declare that I/we have read the regulations of the scheme and
agree to abide by the terms and conditions of the award. I/we certify that the
statements made in the application are correct and if any of the, is found to be
incorrect by the authority whose decision will be binding on me/us. I / we undertake
to refund to the said authority on demand the entire amount of scholarship received
by me/us or overpaid to me/us, failing which the said authority may recover the
amount from me/us through what ever means it deems proper.
Signature of the applicant _____________________________
Date:____________________ Place:___________________
Full name (in capital letter)
__________________________________________________
Relationship of guardian to student _______________________________________

PART – B
( To be filled in by the Head of Institution)
Sr.No. Particulars
1. Duration of the course in which the
applicant is studying
2. Compulsory fees excluding hostel rent and other incidental charges to be paid
by the applicant to the current year from ________ to _________ as per
details given below.
Particulars of all non
refundable
Compulsory fees
payable by the
applicant
Amounts actually payable by the applicant
to the institution.
Particulars I st Term ` IInd Term ` Total `
1. Tution Fees
2. Examination Fees
3. Games
4. Library
5. Medical
6. Identity Card
7. Practical Fee
8. Enrolment Fees
9. Laboratory Fee
10. Subject wise extra
fee, if any such as
Home Science,
Geography
11. + Any other fees
compulsorily
Payable (to be
mentioned itemwise
with amounts).
Remarks
Total `
3. If the applicant is residing in a hostel, indicate if he/she is entitled to free board /
free lodging
4. Certified that :
1. Information given by the applicant in Part – A has been checked and found
correct / has been corrected in red ink
2. The course in which the applicant is studying in this institution is a
postmatric one.
3. This institution is affiliated to _______________________University /
Board and is recognized by the Government of India / State Govt. of
_______________________ minimum qualification required for admission
to that course is passed in the __________________________
examination.

UNDERTAKING
I undertake that the scholarship amount in respect of the applicant if any when
placed at my disposal will be disbursed by me for the specific purposes for which if
is given and the accounts will be regularly rendered to the authority which awarded
the scholarship. In case the applicant leaves the institution or otherwise discontinues
the studies or accepts any other regular scholarship/stipend, the fact will be
immediately reported to the said authority and payment of scholarship to the
applicant will also be discontinued. The undisbursed amount lying with the institution
on account of maintenance charges, fees etc. will also be refunded to the
Government account.
No. _______________________ Signature of the Head of the Institution
Place ______________________ Date ______________________

Note : Please mentione that the Cheque to be Sent on whose Name /
Designation.
(Kindly Provide the below details with proper care. The Department of
Education, Dadra and Nagar Haveli, Silvassa would not be responsible
for returning of Cheque/Demand Draft)
Name of the Institutions ( in
Block letter)
Name of Head of Institution
Designation of the head of
Institution
Address of the Institution
Name of the Branch of
Dena Bank Through Which
payment of scholarship is
desired
* Stamped signature will not be accepted.
(Seal of the Institution)
ANNEXURE – I
a)
Caste and Income Certificate***
This certificate should be signed by either or the following :
“Member of Parliament / Member of state Legislature / Member of Zila
Parishad, Chief Executive Officer in Charge Municipal Committee /
Corporation or such official as may be specifically authorized for the purpose,
by the Government of the State / Union Territory concerned, Mamlatdar,
Dadra & Nagar Haveli”.
b) This is a very important document as the
scholarship is awarded mainly on the basis of this certificate. The issuing
authority is therefore advised to issue this certificate with due caution.
1. certify that to the best of my knowledge Shri/ Kum /
Smt________________________________________________is a permanent
resident of ________________________________________________
( indicate village, Thasil / Taluka ,District and State)

2. Shri / Kum / Smt. ____________________________________________ (Name
of the Student) belongs to the caste / tribe ___________________and subcaste/Sub-tribe
________________His / Her religion
__________________________
3. The total annual income from all sources of the students parent/guardian/
husband ( including the student’s own earning, if any) in the preceding year
ending 31 st March 2012 was ` _____________________( Rupees
_______________________________________________________)
Full name in capital letters
_________________________________________________
Designation _____________________________________
Address ( in full )
** Signature of the issuing authority
*** Certificate not bearing the seal of the issuing authority if that be a Gazetted Officer, will not be
accepted. Others may also affix their seals, if available.
** Stamped signature will not be accepted.
ANNEXURE – II
FORM OF DECLARATION OF INCOME
FORM (A)
( To be given by the parents/guardians when the student is not employed)
Whereas my dependent son/daughter Shri/ Kum. / Smt.___________________
______ Student of
____________________________________________________College has
applied for grant of scholarship. I, Shri_________________________________
son of Shri _______________________________________________
address
___________________________________________________________________
______ declare that my total annual income from all sources in the preceding year
ending 31 st March _________ is ` ___________ as per details furnished below. I
also affirm that particulars of property held by me are ( as per details furnished in the
scheduled hereunder) and that I have correctly indicated the amount of various
taxes, cesses and land revenue paid by me. I made myself personally responsible
for the accuracy of the facts and figures furnished.
I further undertake that in the even of the particulars given in this declaration
being found to be false, I shall refund, to the President of India the whole amount of
the scholarship paid to the said ______________________and the Government’s
decisions, whether the declaration of particular is false-shall be final and binding on
me.
Place _______________ Date
________________

***
FORM (B)
(To be given by the student who is employed)
( Signature)
Father / Guardian
I, ____________________________ _son
of_____________________________
Address
student of
College, have applied for grant of a Scholarship, I hereby declare that my annual
income and the annual income of others members or my family from all sources in
the preceding year ending 31 st March _____________ is ` _______________as per
details furnished below . I further declare that the particulars of property held by me (
and the other members of my family) are as shown below and that I have correctly
indicated the amount of various taxes, cesses, and land revenue paid by me/us. I am
personally responsible for the accuracy of the facts and figures furnished.
2. (a) I have a family to support and it consist of _____________________members.
(b) I have no family to support.
3. I hereby declare and undertake that – in the event of the particulars given in this
declaration being found to be false ( in respect of which the government decision
shall be final and binding on my ). I shall refund to the President of India the whole
amount of the scholarship paid to me.
Place ___________ Date ____________
( Signature )
( Note :- certificate from the employer showing full details of pay D.P., DA,
HRA., CLA, interim relief etc. be produced)
SCHEDULED
Sr.No. Particulars
1. EXTENT OF LAND HELD ( as owner/tenant )
• Area
• Village
• Survey No.
• Land revenue
assessment
2. PROPERTY HELD (Houses, shop ,building ,housed sites etc.)
• House No.
• Street
• Village/Town City

3.
• Area of site
• Rent derived, if
any
• House tax paid
• Address of shop
• Nature of trade.
• Sales tax/Income
tax paid
• Licence No.
SALARIES DRAWN
• Name of the
Employer
• Office/Unit in
which he/she working
• Address
• Monthly
emoluments
• Other benefits like
rent allowances etc
4 OTHERS
• Income from
subsidiary industries
• Amounts drawn as
wages
• Any other income
Place __________________ Signature or left/right hand thumb
Impression of parents, guardians
Date __________________
Name ____________________________________
Address
(N.B :- Mostly the income declaration will be verified by a reference to official
records. As for example in the case of Government servants or those in private
service, the reference to the Revenue Officer, in the case of persons paying income
tax, reference may be made to Income Tax authorites. In the case of shopkeepers,
reference may be made to sales tax figures, sales tax figures could in turn, assuming
a normal profit of 10 percent to 15 % in case of retailers and 15 % to 20 % in the
case of whole sale dealers for grains, etc. and houses, annual rental value can be
easily known by a reference to house tax which is fixed on the basis of rental value.
In the case of landless labourers , small holders, tenants of small size of lands held

and extent of land cultivated as owner/tenant or both and /or a reference to land
revenue records.)

Application Form for Post Matric Scholarship for the Year 2012-13.
GOVT. OF INDIA
DEPARTMENT OF EDUCATION
U.T OF DADRA & NAGAR HAVELI
RENEWAL APPLICATION FORM FOR GOVT. OF INDIA POST MATRIC
SCHOLARSHIP TO SCHEDULE CASTES / SCHEDULE TRIBES AND LOWER
INCOME GROUP STUDENTS.
PART – A
To be filled in by the applicant in neat and clean hand writing
Sir,
I was in receipt of a scholarship under the above noted scholarship scheme last
year for the study of ________________________ ( name of the course of study
and class. )
Name of Institute _________________________________________________
_________________________________________________
And I am studying this year in the ____________________________________Class
of that continue course in that institute.I request that my scholarship may be renewed
for the current year 2012-13 .
Yours faithfully,
( Signature of applicant )
Place: Date :
Sr.No. Particulars
1. Full name in capital letter Shri / Kum/Smt.
2. Fathers / Husband’s Name
3. Caste / Tribes and subtribes
/ sub-caste
4. Whether Married or Single
5. Full Address with Phone
No.
Phone No.
PART – B
( To be filled in by the Head of Institute where the applicant is studying ).
I (a) The statement made by the applicant in part (a) above are correct.
(b) Reference of the sanction letter
No.__________________________________ under which awarded Scholarship
dated ______________ ` ___________
II Character, conduct and attendance of the applicant ( General review ) :-
Result of the annual examination of the class attended in the previous year 20
- 20 where he/she has been promoted to the next higher class or failed /
detained.

Sr.No. Particulars
1. If the applicant has been promoted to the next higher class please indicate
� Class to which promoted
� Date of promoted
� Date of joining in the class
� Date of final exam
2 In case the applicant failed or was otherwise detained please indicate:
� Reason for failure / detention
� Whether this is his/her first
failure or more than one failure in
the entire course.
3. Was the applicant residing in the
hostel in the proceeding year ?
Whether the applicant is residing in the Hostel of the Institute or in approved
hostel this year? If yes please furnish
Name of the hostel
Date of the admission in the Hostel
4. Whether the applicant is entitled to free boarding and lodging or free boarding or
free lodging ?
Is the applicant exempted from payment of tuition fee ? If yes, please indicate
whether exemption is for full or half tuition fee :
Note : Please mentione that the Cheque to be Sent on whose Name
/Designation.
(Kindly Provide the below details with proper care. The Department of
Education, Dadra and Nagar Haveli, Silvassa would not be responsible
for returning of Cheque/Demand Draft)
Name of the Institutions ( in
Block letter)
Name of Head of Institution
Designation of the head of
Institution
Address of the Institution
Name of the Branch of
Dena Bank Through Which
payment of scholarship is
desired

The applicant is required to pay compulsory fees (excluding Hostel rent) and other
incident charge to this institution for the current year from the date
_________________ to _______________ (date) as per details given below :-
Particulars of all non Amounts actually payable by the applicant Remarks
refundable
Compulsory fees
payable by the
applicant
to the institution.
Particulars I st 1. Tuition Fees
2. Examination Fees
3. Games
4. Library
5. Medical
6. Identity Card
7. Practical Fee
8. Enrolment Fees
9. Laboratory Fee
10. Subject wise extra
fee, if any such as
Home Science,
Geography
11. + Any other fees
compulsorily
Payable (to be
mentioned itemwise
with amounts).
Term ` IInd Term ` Total `
Total `
Certified that this institution is affiliated to ______________________________
University / Board and is recognized by the Government of India / State Government
of ______________________. The applicant was awarded scholarship for study in
_________ _____ course in this institute and receipt in the prescribed from his/
her to the effect he / she was paid scholarship in the preceding year is annexed.
I under take that the scholarship amount in respect of the applicant if and when
placed at my disposal will be disbursed by me for the specific purpose for which it is
given and the accounts will be regularly rendered to the authority which awarded the
scholarships. In case the applicant leaves the Institution or otherwise discontinue the
study or accept any other regular scholarship/stipend the facts will be immediately
reported to the said authority and the payment of scholarship to the applicant will be
discontinued. The undisbursed amount lying with me will also be refunded to the
Government account.
Place : Signature of Head of Institute*
Date : (Seal of the Institution)
* Stamped signature will not be accepted.

ANNEXURE – I
Receipt in acknowledgement of the scholarship amount for Rs.
_________________________ Reference of sanction letter No.
_____________________________________________ and date by which awarded
scholarship in the previous year. Period up to which maintenance charged paid
__________________ Received from Director of Education .Dadra & Nagar
Haveli, Silvassa. ( Indicate the authority who awarded the scholarship sanctioned )
a sum pf ` ______________
(Rupees._____________________________________)
In full/part payment of Govt. of India scholarship sanctioned to me for the year 20 -
20 ( for study in scholarship to SC/ST & LIG students through the
principal/Dean/Registrar__________________ College / University.
Date :- Signature of the students
Full Name of Student in block letter :-
Class :-

ANNEXURE – II
Particulars of last University / Final Examination in respect of
Shri / Kum / Smt.
_________________________________________________________.
Name of Institution Year in Aggregate Total Marks (%) of
Examination University which
Obtained Marks
Board taken
obtained to
aggregate.
COUNTERSIGNED
Seal of the Institution. Signature of Head of Institution.
Designation :