MIDAS

SBLUE SC
CHOLAR
RSHIP APP
PLICATIO
ON FORM
M
NOTE:
N
Type or print leg
gibly in blacck ink and inn Capital letter. Last day of submission is Sept 300th,
2015
2
PERSONAL
P
L INFORM
MATION
Last
L Name: ________________________________First Name:__________
_________________________
Gender:
G
Male____ Fem
male____ (Pllease tick whherever appliicable)
Date
D of Birthh: Date____
__Month___
______Year_______
Marital
M
statu
us: Single_____ Married_____ Divorrced____ Widowed____
W
_
CONTACT
TS
Present
P
Add
dress__________________________________________________________________________
__________
_
__________________________________________
____________________________________
__________
_
__________________________________________
____________________________________
Telephone:
T
Home_____
H
___________
_ Mobile_____________
____ Office_______
__________________
Duration
D
of stay at preseent address:Y
Years_____ Months______
Permanent
P
A
Address____
___________
________________________________________________________
__________
_
__________________________________________
____________________________________
__________
_
__________________________________________
____________________________________
Telephone:
T
Home_____
H
___________
_ Mobile_____________
____ Office_______
__________________
Email
E
Addreess:_______
___________
__________________________________________
______________
Name
N
of parrent/guardiann:___________________________________________________
______________
Nominated
N
b : (Enter details
by
d
of thee person whoo informed you
y about thiis scholarship)
Name:
N
____
__________________________________ Contact:____________________________________
How
H did youu hear aboutt this scholarrship: Sociall Media____
__ Friend______ Relativee_____
Others_____
O
_
FAMILY
F
D
DETAILS:
Name

Age (iin
Years
s)

Relatio
onship

Education

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Occu
upation

Monthly income (in Rs

s.)

Approximat
A
te total montthly family expense
e
(in R
Rs.):

ACADEMI
A
IC AND RE
ELATED IN
NFORMATIION
Name
N
of Schhool/Collegee/Institution:________________________________________________________
Address
A
of School/Colle
S
ege/Institutioon:_______________________________________
_______________
__________
_
__________________________________________
____________________________________
__________
_
__________________________________________
____________________________________
Telephone:_
T
_________________________
Email
E
Address:_____
d
______________________
______________________
___________________________
Study coursee (Full
Name):____
N
__________________________________________
___________________
__________
_
__________________________________________
____________________________________
Major
M
Subjeects:_______
__________
______________________
______________________
______________
__________
_
__________________________________________
____________________________________
Annual
A
Feess Rs.______
_________________
Rank
R
in last annual exam
m___________ out of___________
Total
T
marks ___________ out of ___________
Prizes
P
/certifficates receivved in schoool/college/innstitution:
__________
_
__________________________________________
____________________________________
__________
_
__________________________________________
____________________________________
__________
_
__________________________________________
____________________________________
Prizes/certif
P
ficates receivved in other academic coompetitions/ssports etc.
__________
_
__________________________________________
____________________________________
__________
_
__________________________________________
____________________________________
__________
_
__________________________________________
____________________________________
Extracurricu
E
ular interestss/hobbies:
__________
_
__________________________________________
____________________________________
__________
_
__________________________________________
____________________________________
__________
_
__________________________________________
____________________________________
Students asppiration afterr completingg the course:
__________
_
__________________________________________
____________________________________
__________
_
__________________________________________
____________________________________
__________
_
__________________________________________
____________________________________
__________
_
__________________________________________
____________________________________
__________
_
__________________________________________
____________________________________
__________
_
__________________________________________
____________________________________
__________
_
__________________________________________
____________________________________
Any
A other innformation strongly
s
suppporting the rrequest for sccholarship:
__________
_
__________________________________________
____________________________________
__________
_
__________________________________________
____________________________________
__________
_
__________________________________________
____________________________________
__________
_
__________________________________________
____________________________________
__________
_
__________________________________________
____________________________________
__________
_
__________________________________________
____________________________________
__________
_
__________________________________________
____________________________________
__________
_
__________________________________________
____________________________________
__________
_
__________________________________________
____________________________________
2 of 4

Academic
A
performance: (Please shaare details off last 6 years))
Exam

School/Co
ollege

Year of passing
p

Percenttage

Details
D
of sccholarship reequested from
m MidasBluue:
__________
_
__________________________________________
____________________________________
__________
_
__________________________________________
____________________________________
__________
_
__________________________________________
____________________________________
Details
D
of Sccholarship reeceived/Awaaited/Requessted from othher sources for current year:
y
__________
_
__________________________________________
____________________________________
__________
_
__________________________________________
____________________________________
__________
_
__________________________________________
____________________________________
Details
D
of Sccholarship reeceived earliier from MiddasBlue/otheer sources:
__________
_
__________________________________________
____________________________________
__________
_
__________________________________________
____________________________________
__________
_
__________________________________________
____________________________________
Reference
R
foor verifying the informattion given (N
Name, addreess and contaact No. of coonfirmable reeliable
b sources)
__________
_
__________________________________________
____________________________________
__________
_
__________________________________________
____________________________________
__________
_
__________________________________________
____________________________________
Briefly
B
desccribe your go
oals if awardded a MidasB
Blue Scholarrship.
__________
_
__________________________________________
____________________________________
__________
_
__________________________________________
____________________________________
__________
_
__________________________________________
____________________________________
__________
_
__________________________________________
____________________________________
__________
_
__________________________________________
____________________________________
Financial
F
Status (How do
d you plan to
t pay for coollege withouut scholarshiip):
__________
_
__________________________________________
____________________________________
__________
_
__________________________________________
____________________________________
__________
_
__________________________________________
____________________________________

3 of 4

NOTE:
N
Com
mpleted form
m need to be submitted att hr@midasbblue.com aloong with coppy of followiing
documents
d
by
b Sept 30thh, 2015.
1. Identity proof
p
(Adhaar card/PAN card/Driving licence)
2.
2 Student Id
I card
3. 10th stan
ndard mark-ssheet
4.
4 12th stan
ndard mark-ssheet
5. Mark-sheeets for last 6 academic years
6. Birth cerrtificate
7.
7 Address proof

4 of 4