Dwaraka Doss Goverdhan Doss Vaishnav College (Shift-II)

Arumbakkam, Chennai 600 106

Scholarship form for the Academic Year 2023 - 2024

1. Name in Capitals :

2. Class & Roll Number :

3. Address :

4. Mobile Number :

5. Name of Parent/Guardian :

6. Community :

7. Occupation of the parent/Guardian :

8. Annual Income of the parent/ :

Guardian (The income of the
Father and mother should be
Furnished, if both are
Employed. The income should
Be certified either by the
Employer or Tahsildar)-
Produce photocopy of the
Current month salary
Certificate.

9. List of family members

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S.no Name Relationship with Occupation/ Income
Head of the family Dependent
----------------------------------------- ----------------------------------
01)

02)

03)

04)
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10. Particulars of the examination passed and percentage (Enclose Photocopies)

XII Standard :

I Year :

II Year :

III Year :
11) a) Were you in receipt of :
Any scholarship last year

b) If answer is ‘yes’ :
indicate the name of
scholarship and value

12) Have you applied for any :

Other scholarship this year

13) Referred by :

UNDERTAKING
I declare that the information given above is true and correct.

I am not in receipt of any scholarship, stipend or fee concession from any other source and I shall intimate the
management at once if I am selected for award of any other Scholarship in future.

I promise that I shall abide by the rules and regulations and devote attention to my study by attending the class
regularly and write all the examination conducted by the college.

I also promise that I will refund the scholarship if there is shortage in attendance.

Signature of parent/Guardian Signature of the candidate

Note: a) Please enclose photocopy of Mark-sheet, Income certificate, Community certificate.

b) Scholarship, if disbursed will be for the current Academic year only.

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FOR OFFICE USE ONLY
College Fees :

Paid Fees :

Any fees due (Previous Year) :

Scholarship amount sanctioned :

Principal Secretary Treasurer