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Common Application Form: For Award of Scholarship (CAFAS)
Common Application Form: For Award of Scholarship (CAFAS)
Common Application Form: For Award of Scholarship (CAFAS)
DepartmentofHigherEducation,GovernmentofOrissa p g ,
Theapplicationformshouldbefilledin CAPITALLETTERS onlyandinapplicant'sownhandwriting.
ForDHEuseonly FORMNO.
forAwardofScholarship(CAFAS)
1.NameoftheScholarship appliedfor
2.Scholarship Code Affixselfattested(on thefront)recentcolour the front) recent colour passportsize photographhere.Don't staple.
f MotherTongue f. M th T
6. Fullnameof FATHER 7. Fullnameof MOTHER 8. Profession& occupationof FATHER 10. CorresepondenceAddress a. HouseNo. c. PostOffice e. Tehsil g. State i. Telephone(withSTDCode) j. MobileNumber 11. PermanentAddress(Itmaynotbefilledup,ifPermanentAddressissameasCorrespondenceAddress) a. HouseNo. a House No c. PostOffice e. Tehsil g. State 12. Fullname& addressof b. b Street/Village d. Block/ULB f. District h. PINCode 9 Profession& occupationof MOTHER b. Street/Village d. Block/ULB f. District h. PINCode
theGUARDIAN (Ifparentsarenotalivepleasegiveguardian'sname&address) a. HouseNo. c. PostOffice e. Tehsil g. State i. Telephone(withSTDCode) j. MobileNumber 13. IfapplyingforScholarshiptoChildrenofSchoolTeachers(STC),thenpleasegivethefollowinginformation Ifprofessionofeither/bothparentsisteachinginGovt./Aidedschoolsasperitemno.8&9above,pleasewritename& a. NameoftheSchool b. Street/Village d. Block/ULB 14. IstheapplicantaHosteller?[puttick( )whicheverisapplicable]
(Ifyes,attachBoardercertificatefromconcernedauthority)
15. Annualincomeofparentsfromallsources
(Attachincomecertificate/incomecertificateandaffidavit,fromappropriateauthority,ifapplicable)
Yes
No
d. Datefromwhichreceived
Yes
DD/MM/YYYY No
Whethertheapplicanthasappliedforanyotherscholarshipduring2009?
b. Ifyes,nameoftheScholarship
c. Dateofapplication
DeclarationbytheApplicant
I,Sri/Ms./Smt.............................................................................son/daughter/wifeof.....................................................dohereby declarethatallinformationgivenabovearetruetothebestofmyknowledge&belief.Iwillabidebyallrulesand regulationofthescholarshipscheme,ifselected.Iamnowpursuing.............................coursein .............................................................................................College/Institution.Iamnotinreceiptofanyscholarshipforthis coursenorshallreceiveanyotherscholarshipduringthecourseperiod.
Date Place .. ..
FullSignatureofApplicant
StudentshipCertificatebytheHeadoftheInstitution
Certified that Sri/Ms./Smt. ................................................................................... has been admitted in to this institution on .......................... as a regular student in the course ....................................... during the academic session,, 200910 bearing Roll g g g No. .......................... The above information furnished by the applicant are true to the best of my knowledge and based on records. His/Her rank in the Entrance Test conducted by ........................................................ is ................................ on the basis of whichhe/shehasbeenadmittedintothisInstitution. Thisapplicationiscountersigned. This application is countersigned
SignatureoftheHeadofthe Institutionwithdate&seal. Essentialenclosures 1 OriginalResdentialCertificateinproformaasinAppnedixA 2 Originalincomecertificateofparentsfromemployerand/orappropriateauthority(applicableforJP,SP,PP,STC,TG&TM) 3 Incomeaffidaivtofparents/guardianinproformaasinAppendixB(applicableforTG&TM) 4 Attestedcopyofmarksheetoflastqualifyingexamination(e.g.10thBoardmarksheetforJM&JP) 5 Attestedcopyofpasscertificateof10thStd.Exam/+2Exam/DegreeExam,whicheverisapplicable. 6 ServicecertificateasinAppendixCfromHeadmasterofthschool&countersingedbyDI/CIofshools,(applicableforSTC) 7 BoardercertificateiftheapplicantapplyingforSchoalrshiptoTeacher'sChildren(STC)isaHosteller 8 AttestedcopyofrankcardissuedbythechairmanofOJEE/AllIndiaTest.(applicableforTG&TM) 9 Selfattseted(onfront)passportsizephotographtobepastedatthefrontrightcorneroftheCAFAS. 10 AttestedcopyoftheBankPassBookshowingnametheapplicant&accountnumber.
Appendix -A
Note: - Revenue officer means the Chief Officer in change of the Revenue Administration of the District, Sub-Division or
Tahasil and includes Addl. District Magistrate, Sub-Divisional Officer, Tahasildar and Addl.Tahasildar.
Appendix B
Appendix- C
School Seal
Countersignature & seal of the DI/CI of Schools
Appendix D
Certified that the aforesaid awardees have been promoted to the next higher class & eligible for renewal of the Scholarship mentioned at Sl No. 5 above during the session-2009-10. An amount of Rs.. (Rupees ..)only sanctioned /placed during the last Financial Year vide DHE(O) letter No. .dt has been fully utilized /paid to the concerned awardees. The attested copies of mark sheets in respect of above awardees are enclosed herewith.