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25October2016,11:06AM

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DirectorateofTechnicalEducation
TransactionID 1474953890568

Proceduretoapply:
1.Filltheapplicationformandsubmititonline
2.GotoinboxandprinttheapplicationformbyclickingonthereferenceID.
3.SubmittheprintedhardcopywithrequireddocumentstotheDirectorateofTechnicalEducationNagalandkohima
797001eitherbypost/hand.

GovernmentofNagaland
DIRECTORATEOFTECHNICALEDUCATION
StudentID DTE201617286R
NAGALAND:KOHIMA

Notedow nthisID.Withoutthisid
FORMATOFAPPLICATIONFORSTIPENDTO youcannotrenew your
STUDENTSBELONGINGTOSCHEDULED scholarshipnextyear
TRIBESOFNAGALANDFORTECHNICAL
STUDIESWITHININDIA.
ForRenewalCandidatesOnly

StudentDetails PleaseSelect Degree *

1. Nam eofthecandidate
FirstNam e * YIMKUM
MiddleNam e I

LastNam e OZUKUM

2. (a)Nam eofFather/Guardian * IMTILEPZUK

(b)OccupationofParent/Guardian * GOVERNMENTSERVANT

(c)Parent/GuardianAnnualIncom e * Rs. 6,00,000

3. Nam eofMother * MERAINLA

4. DateofBirth * (ddm m yyyy) 01101994

5. Gender * Male Fem ale

6. Nationality * INDIAN

Perm anentResidentialaddressofthecandidate.

7. Tow n/City * DIMAPUR

8. District * Dimapur
9. State * NAGALAND

10. PinCode * 797112

AddressofCandidateforcorrespondence
11. College * BITSPILANI

12. Tow n/City * PILANI

13. District * JHUHJHUNU
14 State * RAJASTHAN
.
15. PinCode * 333031

DetailsofEducationalQualificationforMatriculation(HSLC)&10+2(HSSLC)
PercentageObtained
Board

16. Matriculation(HSLC) * HSLC 94.83 %

17. 10+2(HSSLC) HSSLC 91.33 %

https://www.nagaland.gov.in/portal/authsec/portal/StatePortal/default/Inbox/SPEFormInboxPortletInstanceWindow?formName=sp_technical_renewal&action= 1/4
10/25/2016 UserInboxGovernmentofNagaland::OfficialPortal

CourseDetails
18. (A)Nam eoftheCourseinw hichthecandidatehasbeenadm itted. * B.TECH

(B)PercentageofMarksobtainedintheQualifyingExam ination(ClassX/10+2/Degree/ * 91.33 %
PG)AttestedcopyoftheMarkssheetshouldbeenclosed.

(C)Minim um Qualificationrequiredforadm issioninthecourse 75

(D)Selectw hethertheinstitutionw herethecandidatehasbeenadm itted,isrecognizedbyAll * Yes No

IndiaCouncilforTechnicalEducation/Governm entofIndia/Governm entofConcernedState.

19. Durationofthecourse *

20. Academ icYear * 4

21. FulladdressoftheInstitute/Universityw herethecandidatehasbeenadm itted
BITSPILANI
(a)Nam eoftheCollege/University *
PILANI
(b)City/Tow n *
(c)District * JHUNJHUNU

(d)State * RAJASTHAN

(e)PinCode * 333031

(f)InstitutePhoneNum ber

22. DateofCom m encem entofSession *(ddm m yyyy) 01082016

01062017
23. ExpectedDateofCom pletionofCourse * (ddm m yyyy)

Yes No
24. Whetheralreadyinreceiptofstipend/scholarship? * IfYes,pleasestate

(a)SourceofStipend/Scholarship

(b)TheAm ountofScholarship/Stipend

25. ScholarshipAm ounttobepaidtostudent Rs. 6400

ScheduledTribeDetails

26. Selectw hetherbelongstoScheduledTribesofNagaland. * Yes No

27. Pleasefurnishthefollow ing

(a)Nam eoftheTribe * Ao Others

Ifothers,pleasespecify *

Mokochung
(b)Districtw hereTribeisSettled *
(c)Tow nw heretribeissettled * MOKUKCHUNG
(d)Statew heretheTribeisSettled * NAGALAND

FeesDetails
28.Particularsofallnonrefundable
com pulsaryfeespayablebythe
applicant Am ount(Pleaseentertheam ountonannualbasis)

1.TuitionFee 250000

2.RegistrationFee 0

3.Exam inationFee 0

4.PracticalFee 0

5.Gam esFee 0

6.LibraryFee 0

7.Student'sUnionFee 0

8.MagazineFee 0

9.MedicalFee 0

10.OtherFee 0

TotalAm ountRs. 250000

BankAccountDetails

29.StudentspersonalBankAccountNo.: * 0000031813498955

https://www.nagaland.gov.in/portal/authsec/portal/StatePortal/default/Inbox/SPEFormInboxPortletInstanceWindow?formName=sp_technical_renewal&action= 2/4
10/25/2016 UserInboxGovernmentofNagaland::OfficialPortal
30.Nam eofBank: * STATEBANKOFINDIA
31.IFSCCodeoftheBank: * SBIN0010762

32.AddressoftheBank * PURANABAZARDIMAPUR

33.BranchCode * 010762

34.AadhaarNum ber

Note:
IFSCcode,BranchCodecanbeAccessed/Locatedfromthewebsite"www.bankifsccode.comorfrontpageofyourbankpassbook.

YourformwillbeprocessedatKohimaDistrict
DeclarationbytheApplicant *

* Idoherebydeclarethattheparticularsfurnishedbym einthisapplicationform arecorrectandcom pletetothebest

ofm yknow ledgeandbeliefthatIhavenotconcealedanyfactorfurnishedanyinaccurateorfalseinform ationw hich
w illrenderm yapplicationliabletobesum m arilyrejected.

27092016 YIMKUMIOZUKUM
DATE *
PLACE * PILANI FullNam eoftheCandidate *

BITSPILANI
SignatureoftheDean/Competent
Nam eofInstitute * Authorityw ithseal

ANNEXUREB

INSTRUCTIONSTOAPPLICANTSFORSUBMISSIONOFDOCUMENTSANDOTHERDIRECTIVES:

1.OnecopyofrecentPassportsizephotographdulyattestedbytheheadoftheInstitution.

2.AttestedcopyofHSLC/10+2/Degreem arksheetsandadm itcardsalongw ithallotherrelevantcertificatesin
respectofallexam inationspassed.

3.AcertificateoftribeandIndigenouscertificatedulyattestedbyaGazetteOfficer.

4.Aduplicatecopyofthenom inationletterissuedbytheDirectorateofTechnicalEducationNagalandunderstate
quota.

5.Fortheaw ardofstipendthestudentm usthave60%andaboveattendanceateverystageofstudy.Anystudentby
reasonsofhis/herow nactofdefaultfailstom akesatisfactoryprogressinattendanceorhasbeenguiltyof
m isconductsuchasresortingtoorparticipationinstrikesw ithouttheperm issionoftheconcernedauthority,the
sanctioningauthoritym ayeithercancelthestipendorstop/w ithholdfurtherpaym entofstipendforsuchperiodasit
m aythinkfit.

6.Ifstudentisfoundtohaveobtainedastipendbyfurnishingthefalsestatem ent,docum entshis/herstipendw illbe
liabletofullrecoveryatthediscretionofthegovernm entofNagaland.

7.TheDirectorateTechnicalEducationNagaland,Kohim ashallnotberesponsibleforanylossofapplicationform s/
docum entssendbypost.

8.Theregulationscanbechangedatanypointoftim eatthediscretionofGovernm entofNagaland.

9.Thepaym entofstipendissubjecttothereleaseoffundbytheFinanceDepartm ent,Governm entofNagaland.

10.Incom plete/inaccurate/Falseinform ationfurnishedintheapplicationForm shallbesum m arilyrejected.

11.InstructionsforPassportsizePhotograph
(a)Encloseyourrecentidenticalpassportsizephotograph(4.5cm X2cm )show ingfrontalview offullface.
(b)Photographshouldhaveaw hiteorlightcoloredbackground.
(c)Photographw ithcoloredordarkglasses,Polaroidprintsorcom puterprintsw illnotbeaccepted.

12.Docum entstobeattachedw iththehardcopy

(a)Marksheetofpreviouscourseleveli.e10+2fordegreeFreshstudents.
(b)Previoussem estersMarksheetforDegreeRenew alStudents.
(c)MarksheetofPreviousCourseLeveli.e10+forDiplom aFreshStudents.
(d)PreviousSem estersMarksheetforDiplom aRenew alStudents.
(e)ScheduleTribeCertificate.
(f)IndigenousCertificate.
(g)BankAccountPassbook.

Note:TheInstituteauthoritiesarerequestedtoallowthestudentstoapplyforbothMeritcum
Means(minority)andStateScholarship.UndertheMinorityScholarshipthereisnoguaranteein
awardofscholarshipastherearefixedno.seats.

FOROFFICEUSEONLY(SCHOLARSSHOULDNOTWRITEBELOWTHISMARGIN)

ISSUEDBY RECIEVEDBY DATE

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