INSTITUTION VERIFICATION FORM

2016-17
Verification/information to be furnished by the Head of
institution/college:

It is certified that the information provided below by _________________ who is

admitted in ________________ course for the academic session ___________ in
______________ is correct as per the records/documents verified with a copy of it
maintained in institution/college, He/ She is a hosteller/day scholar of the college.

Last year marks details:

Fee details current year:

es
In case the information filled in these columns is not correct, then the institute

iti
should indicate that separately.

e r
___________________________________________________________________________

or o
___________________________________________________________________________

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For Renewal of Scholarship:

It is certified that the student has not changed the course of study and/or the
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institution of the study for which the scholarship was originally awarded /has
changed the course of study and/or institution with prior approval of the state
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government (Please strike out which is not applicable).

at
or
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Date: Signature of the head of the institution/college

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Place: with official seal

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Note:
(i) The verification by institution is mandatory for consideration of the
application.
(ii) Students are directed to take the print out of ‘Institution Verification
Form’ get it verified by their institution, in order to apply for minority
scholarship.
 SELF DECLARATION OF FAMILY INCOME UNDER POST MATRIC SCHOLARSHIP
(CLASS XI AND ABOVE) / MERIT CUM MEANS (TOP CLASS) SCHOLARSHIP
SCHEME OF MINISTRY OF MINORITY AFFAIRS, GOVERNMENT OF INDIA
2016-17

I, ____________________________Son/Daughter/of___________________________
Resident of (full address)__________________________________________________
______________________________________________________________________
do hereby solemnly affirm and declare as under :-

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a) That I am citizen of India.
b) That annual income of my family from all sources is Rs ………………(in words

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also) ……………………………………………………………………………………

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or o
c) I declare that my father/mother/both* is/are earning Member(s) in my family.
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2. I certify that the above information given by me is true.
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3. In case this information furnished by me is found false, the financial assistance

awarded to me may be recovered with penal interest and I will be liable to a legal action
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against me in accordance with law.

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or
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Signature of Candidate:__________________________
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Name of Candidate: ____________________________

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Name of School/Institution:_______________________

Enrollment No. in the School/Institution:_____________

Academic Year:________________________________

*Strike off the non-applicable part in the underlined clause above.

 SELF DECLARATION OF MINORITY COMMUNITY BY STUDENT FOR POST MATRIC /
MERIT CUM MEANS (TOP CLASS) BASED SCHOLARSHIP SCHEME
2016-17
Proforma for declaration of Minority Community to be uploaded along with the mandatory
documents for claiming scholarship.

DECLARATION

I, ____________________________Son/Daughter/ward of __________________________

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hereby declare that I belong to the____________________________

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(Muslims/Sikhs/Christians/Buddhists/Jains and Zoroastrians (Parsis) which is a notified minority

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community as per Section 2(c) of National Commission for Minorities Act, 1992).
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Date:__________
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Place:_________
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at

Signature of Candidate: ______________

or

Name of Candidate: _________________

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 Submit the printout of filled in application along
with Xerox copies of the following to your District
officer for Minorities. (Studying College/Institute
District).
1) Marks Cards: -
a) Previous year/Sem Marks Card.
b) Previous Course Marks Card.
2) Fee Receipts.
3) Declarations: -
a) Institute Verification Form.
b) Self-Declaration of Income Certificate by the Student.
c) Self-Declaration of Minority Community Certificate by
the Students
Note: - Formats of a,b & c & are available on website.
4) Proof of bank account in the name of student (1st page
scan copy of bank passbook).
5) Aadhar Card.
6) Passport size 2 Photos.
7) Domicile Certificate, (Aadhar, Election ID, Ration Card,
Driving Licence.)

District Office Address and Phone No

Sl.N TelePhone
District Name E-Mail Id Address
o No.

District Officer Minority Welfare

Department,
Bangalore Muktair 080 - dominority401
1 1st Floor, Podium Block,
Urban Pasha (DOM) 22866718 @gmail.com
Dr Ambedkar Veedi, Bangalore - 01,
Bangalore Urban District

District Officer Minority Welfare

dombengalurur
Bangalore Abdul Azeez.H 080 - Department,
2 ural@gmail.co
Rural (DOM) 22866966 1st Floor, Podium Block, Bangalore-
m
01, Bangalore Rural District

District Officer Minority Welfare

Prakash
0831 - dobcmbelgaum Department,
3 Belgaum Aragapur
2407247 m@gmail.com Taluk Panchayath Office BC Complex
(BCM)
Belgaum-590001

District Officer Minority Welfare

Suresh Babu 08392 - dobcmbellary@ Department,
4 Bellary
(DOM) 245755 gmail.com No.52, Old trunk Road,Opp Ashirvada
School Bellary-583101
 District Officer Minority Welfare
Department,
Abdul Majid 08482 - domwbidar1@g
5 Bidar District Old Government Hospital,
(DOM) 230150 mail.com
Manniyar Thaleem, Near Zilla
Panchayat Office, Bidar-585401

District Officer Minority Welfare

Mashakesab Department,
08354- domwdbgk@gm
6 Bagalkote Melinamani Moulana Azad Minority Complex,
236419 ail.com
(DOM) District Administration Complex (Near
District Training) Bagalkote-587103

District Officer Minority Welfare

Department,
Chickmagalor Manjunath 08262 - domcmangalor
7 1st Floor, Jyothi Nagara,
e S.R (DOM) 220065 e@gmail.com
Zilla Panchayat Complex,
Chikmagalur-577101

District Officer Backward Classes &

Mahesha 08194 - dobcmchitradu Minority Welfare Department, Devraj
8 Chitradurga
(BCM) 235034 rga@gmail.com Urs Bhavana, Stadium Road,
Chitradurga-577501

District Officer Backward Classes &

dobcmchamara Minority Welfare Department, No131
C.Shiva 08226 -
9 Chamrajnagar janagara@gmail & 132, Administration Bhavan
Kumar (BCM) 222180
.com B.Rachaiyak, Double Road
Chamarajnagar-571313

District Officer Backward Classes &

Jagadeesh dobcmchikkab Minority Welfare Department, #B 4,
08156 -
10 Chickballapur Ganganawar allapura@gmail Second Floor, District Complex,
277053/54
(BCM) .com Shidlaghatta Road,
Chikkaballapura-562101

District Officer Minority Welfare

B.S
0836 - domdharwad@ Department, Behind R.N.Shetty
11 Dharwad Doddamani
2445590 gmail.com Stadium, KHB Colony, Dharwad-
(DOM)
580001

District Officer Minority Welfare

Department, (I/C) Room No.3,Lalbagh,
Dakshin Usman A 0824 - dkminorityoffic
12 2nd Floor, Vanijya Sankirna, Near
Kannada (DOM) 2211078 er@gmail.com
Mangalore Mahanagara Palike,
Mangalore-576004 Dakshin Kannada.

District Officer Minority Welfare

Department,
44, 'A' Block, 2nd Floor,
District Administrative Building,Karur
Veeresh 08192 - domdvg1@gmai Cross, Harihara Road,
13 Davangere
Kumar (DOM) 250022 l.com Davanagere-577006
 District Officer Minority Welfare
Department,
Mehaboob 08472 - domgulbarga@
14 Gulbarga Beside Parliament Member Office, Mini
Basha (DOM) 247260 gmail.com
Vidhana Soudha, Compound,
Gulbarga-585101

District Officer Minority Welfare

Ravi L Department,
08372 - domingadag20
15 Gadag Gunjikar 1st Floor, Mulgunda Naka, Sub
233936 13@gmail.com
(DOM) Division Office Complex,Gadag-
582101

District Officer Backward Classes &

K.T Nigan Minority Welfare Department,
08172 - dobcmhassan@
16 Hassan Rajappa Padma Shree Commercial Complex,
268372 gmail.com
(BCM) Palike Hotel, beside, RC Road,
Hassan-573201

District Officer Minority Welfare

08375 -
Dr. Raju N.K dominoritiesha Department, Nelanagowda Complex,
17 Haveri 24505/249
(DOM) veri@gmail.com 1st Floor, Opp LIC, P.B.Road
008
Haveri -581110

District Officer Minority Welfare

Vishwanath 08152 - domkolar@gma Department, Hanumegowda Complex,
18 Kolar
(BCM) 220257 il.com Behind Narendra Hospital, M.B Road,
Kolar-563101

District Officer Backward Classes &

Minority Welfare Department, Devaraj
Suresh K.V 08272 - dobcmkodagu@
19 Kodagu Urs Bhavana, General Thimmaiah
(BCM) 225628 gmail.com
Ground, Near Mains Compound
Kodagu-571201

District Officer Backward Classes &

B.Kallesh 08539 - dobcmkoppala Minority Welfare Department, Zilla
20 Koppal
(BCM) 221606 @gmailt]com Adalitha Bhavana Hospete Road,
Koppal-583231

District Officer Minority Welfare

Department,
0821 - gokdom.domys
21 Mysore Putraj (DOM) #1179, D 17, 8th Cross, Devaraj Urs
2422088 @gmail.com
Road, Bhima & Brothers Jewellary,
Backside, Mysore-570024

District Officer Backward Classes &

Minority Welfare Department,
Renuka Amba 08232 - dobcmmandya H.K.Veeranna Gowda Road, Near Old
22 Mandya
(BCM) 220835 @gmail.com Taluk Office, Mandya-571401

District Officer Minority Welfare

Pujar 08532-
dominorityraic Department, Harap Mohalla, Goshala
23 Raichur Vermallapa 226555/23
hur@gmail.com Road, Tipu Sultan Circle
(BCM) 1710
Raichur-584101
 District Officer Backward Classes &
Shiv Kumar 08532- dobcmramanag Minority Welfare Department
24 Ramnagara
(BCM) 276047 ara@gmail.com 2nd Floor, Zilla Panchyat Bhavan, B.M
Road, Ramanagar-562159

District Officer Minority Welfare

Dharmappa.T 08182 - domshimoga@g Department, Above Chairman’s Room
25 Shimoga
(DOM) 220206 mail.com 2nd Floor Zilla Panchayath Building
Kovempu Road Shimoga-577201

District Officer Minority Welfare

M.Mehaboob 0816 -
domtumkur@g Department
26 Tumkur Pasha 2273724/2
mail.com 1st Main 1st Cross Shivanilaya
(DOM) 278014
Gandhi Nagar, Tumkur-572101

District Officer Minority Welfare

08382 -
Uttar B.M Badiger domuttarakann Department, Old Deputy
27 220336/22
kannada (DOM) ada@gmail.com Commissioner Office Complex,Karwar-
6589
581301 Uttara Kannada

District Officer Backward Classes &

Harish L Minority Welfare Department,
0820 - dobcmudupi@g
28 Udupi Gaonkar No.304, 2nd floor, B Block, Rajathadri,
2574881 mail.com
(BCM) Manipal, DC Office Compound, Udupi-
576104

District Officer Minority Welfare

Department,
Gangadhar
08352 - dominoritybijap Flat No.867, Vahida Risaldar Building,
29 Vijayapura Doddamani
276523 ur@gmail.com Near Ganapati Temple, Keerthi Nagar,
(DOM)
Managooli Road,
Vijayapura-586101,

District Officer Backward Classes &

Minority Welfare Department
Maruthi 08473 - dobcmyadgiri0
30 Yadgir CMC Complex, Opp Govt Degree
Hujrat (BCM) 253742 2@gmail.com
College. Chittapur Road, Yadgiri-
585202