Government of India

NEW CENTRAL SECTOR SCHOLARSHIP SCHEME OF TOP CLASS EDUCATION

For Scheduled Castes (SCs)/ Scheduled Tribes (STs)

Application Pro-forma (Fresh)

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Admission Year ..

(All entries in Capital Letters only & to be submitted in duplicate and obtain acknowledgement on your copy)

1 Name of Student

2 Date of Birth

3 a) All India Rank (JEE 2016)

b) JEE Roll No

c) Candidate Category

d) Allotment Category

e) Branch to which admitted

f) State of Eligibility

4 Institute ID No

5 Section / Roll No / Batch

6 Contact Ph / Mobile No

7 a) Fathers Name

8 b) Fathers Occupation and Name and Address of

organization/office in which working, Ph Nos / Mob.

c) Fathers Annual Income (amount in Rs) (attach

Form No 16 OR Annual Income Tax Return of

previous financial year )

9 a) Mothers Name

b) Mothers Occupation and Name and Address of

organization/office in which working, Ph Nos / Mob.

 c) Mothers Annual Income (amount in Rs) (attach

Form No 16 OR Annual Income Tax Return of

previous financial year )

10 Sum total of 8 (c) and 9 (c)

11 Residing with parents Yes / No

12 Residing in VNIT hostel Yes / No

Hostel Block No / Room No ./.
13 Residing in other than VNIT hostel / Govt Hostel Yes / No
Name of Hostel
Address and Ph No.
14 Bank Account details
Bank Name
Account No
15 Parent/s Name and Address, Contact Ph/Mob Details

Encl 1) JEE Score card 2) PI reporting letter 3) Caste certificate 4) Income certificate issued by District / Tahsil revenue
authority along with Form 16 of year 2015-16 and / or copy of Annual Income Tax return filed 5) Copy of Bank Account
details 6) Copy of Aadhar Card 7) Hostel residence certificate (For Hostellers)

Declaration
I, hereby solemnly declare that the information furnished above is true to the best of my knowledge and belief. In
understand that If any information furnished by me is found to be incorrect at any stage, I am liable for disciplinary action
and my nomination for the award of scholarship shall be cancelled and the entire amount of scholarship paid to me will
be recovered from me. Further I understand that the award of scholarship and its continuation for further years of study
of the program to which I am admitted shall be subject to satisfactory performance at the end of every year as per the
criteria laid down in the norms of scholarship. I understand that the award of PC under the scheme is for the Academic
purpose & I will be solely responsible for its unlawful/unethical use. I assure that the warranty seal along with the laptop
serial no. will not be damaged / tampered. Also I promise to pay any losses / sustain the damage / loss / theft of the
system. The rules and regulations of the Institute and the provisions / norms for the award of scholarship are acceptable
to me. I also declare that I will undergo such punishment as may be imposed by the Authorities for errors and / or
omission including suppression of facts etc. if any.

Date: (Name & Signature of Student)