Details of online application form for post-10th scholarship and fee reimbursement (new) session

- (2023-24)
(For submission in educational institution)
Print date:- 04/03/2024
Registration Details
District Name: AGRA
Name of Educational Institution : DEEMED UNIVERSITY, DAYALBAGH
Registration Number: 150250502304127
Name of the student: Vivank Tyagi
If the changed name of the
student is:

Father's / Husband's name: S/O: Yogesh Tyagi

mother's name:
Religion: Hindu
Class/Caste Group: general class
date of birth: 06/06/2005
gender: MALE
Mobile, Telephone No .: XXXXXX0205 ,
E-mail
Dayalbagh
year of high school
high school board Educational Institute, 2021
graduation
Agra
Name and address of the
High School Board Roll university/institution
1902482
Number from where you have passed
high school

Academic Details
1-Course Name:
2-Branch of course:
3-Type of course:
5-Entry is based on lateral entry NO
7-Date of admission in the first
year of the course:
9-Registration number in
University/Board/Affiliating
Agency
11-Is admission in professional
course based on class 12
marks/merit:
13-Whether admission to the
current course is through
entrance examination through
(UPSEE(AKTU)/JEECUP/NEET)
15-Counselling Number
17-Rank obtained in entrance
examination
19- Details of educational qualification (high school and other higher classes) for the last years
B.TECH/BE
BACHELOR OF TECHNOLOGY (ELECTRICAL ENGINEERING)
self financed 4-Class year and duration: 1,4
6-Residential/Day Students: Day scholar
8-Date of admission in the
21/07/2023 21/07/2023
current session of the course:
10-Name of the
DEEMED UNIVERSITY,
University/Board/Affiliating
DAYALBAGH
Agency:
YES 12-Course Eligibility: intermediate
NO 14-Entrance Exam Type
16-Entrance Exam Year Sele
18-Cut-off marks obtained in
0 0
entrance examination
 Name of the
serial
educational qualification passed year Integer score Percent Board/University/Affiliating
number
Agency
1 High School 2021 500.00 483.00 96.75 dei board
2 intermediate 2023 500.00 406.00 80.92 dei board

personal details
20-Sub caste:
21-Residential permanent SHIVNAGAR GANGE GAURI BAGH BALKESHWAR AGRA - SHIVNAGAR
address: GANGE GAURI BAGHBALKESHWAR AGRA
SHIVNAGAR GANGE GAURI BAGH BALKESHWAR AGRA - SHIVNAGAR
22-Correspondence address :
GANGE GAURI BAGHBALKESHWAR AGRA
23- Ration Card Number/Family
114640058171
ID :
24-Disability type (if disabled):
(ii)-Disability Allowance (in Rs):
25(i)-Disability %

(iv)-Disabled Application
(iii)-Disabled Certificate Number
Number:

Caste and Income Details

26-Caste Certificate Number , 27-Date of issue of caste certificate: ,
28-Caste Certificate Application Form No:
29-Income of the student's family from all 96000
30-Income Certificate No. 152221052643
sources (Rs.): annually
31-Date of issue of income certificate: 05/09/2022 32-Income Certificate Application Form No.: 221460010142426

bank details
The amount will be paid into the Aadhaar seeded bank account from the Aadhaar number. Bank account is not to be mentioned.

Fee related details

39(i)-Approved Annual Non-Refundable Compulsory Fee: 12700

last year details

(ii)-Previous year's examination annual examination
40(i)-Last year's exam result: PASS
system: system
Annual Exam Marking
(iii)-Last year's marking system:
System
(iv)-integer of last year 500.00 (v)- Last year's marks 408.00
(vii)-Name of the educational DEI REI INTERMEDIATE
(vi)-Percentage of last year 81.60
institution COLLEGE AGRA

Form Submission Date:-sion Date:- 07/01/2024

manifesto 92EE0BDEF300F20FE1A9B8F5734B5414

I hereby declare that the above entries/information are correct and have been filled by me only, I am not receiving any other scholarship from any other source and I am not serving
anywhere. If I am serving, the total annual income of me and my parents or guardian is less than Rs. 2.00 lakh (for SC/ST, it is less than Rs. 2.50 lakh). Annual return has not been
filed by my parents in the Income Tax Department. I have not taken admission anywhere else apart from this institute. I will properly comply with the educational instructions of the
institute and the minimum attendance of 75 percent prescribed for scholarship and fee reimbursement.
If any information given in the application form and attached residence and income certificate along with the annual income of my parents is more than Rs. 2.00 lakh (Rs. 2.50 lakh
for SC/ST) and other records are found to be incorrect. Then I will return the amount of scholarship and fee reimbursement along with penal annual interest. If I fail to do so, the
department will be free to recover the amount received from me as revenue dues and take legal action against me.
I, the holder of Aadhaar number, hereby give my consent to SW/ST/OBC/Minority Departments to obtain my Aadhaar number and Demographic/OTP for Authentication with UIDAI.
SUB-AUA (SW/ST/OBC/Minority Departments) has informed that my Aadhar number will not be stored/shared and will be submitted to CIDR only for the purpose of
SC/ST/Gen/OBC/Min Scholarship benefits.
I give my consent for demographic and OTP authentication with Unique Identification Authority of India by obtaining my Aadhaar number from the concerned departments for
SC/ST/General Class/Backward Class/Minority Scholarship. My Aadhaar number will not be shared/protected and will be used for scholarship schemes.

Date : ................................ Place : .............. .....................

Signature/thumb impression of mother/father Signature of student
(Guardian in case of death of parents)

Receipt-Session- (2023-24) - Category - General Category

Appendix – 'Ch'
Registration Number:- 150250502304127
92EE0BDEF300F20FE1A9B8F5734B5414

Receipt of application form for Dashmottara scholarship and fee reimbursement

Mr./Mrs./Mrs. Vivank Tyagi S/o./Daughter/Wife Mr. S/O: Yogesh Tyagi
Institution DEEMED UNIVERSITY, DAYALBAGH Course B.TECH/BE
Original/self-attested copies of the following records were obtained along with the application form for
post-tenth scholarship and fee reimbursement.
(To be checked and ticked by the office of the educational institution)
1- Photocopy of the income certificate of the applicant's mother/father/guardian (on the
prescribed format).
2- Photocopy of the caste certificate of the applicant (on the prescribed format).
3- Photocopy of receipt as proof of fee deposited in the institution. Not necessary for Scheduled
Castes and Tribes.
4- If there is a gap between two classes, then a self-attested affidavit to that effect.
5- If the student is staying in a hostel, then a copy of the fee receipt/certificate provided by the
hostel.
6- Photocopy of the passbook of the applicant's bank account on which the account number and
IFS code are mentioned.
7. Photocopy of high school mark sheet/certificate.
8. Certificate of passing the previous examination.
1. Photocopy of mark sheet.
2. Photocopy of the certificate.
(Signature of the officer/employee of the educational institution receiving the application form)
Name:
Designation:
Date:
With the seal of the institution.
Details filled by the educational institution at the time of forwarding the form (2022-23): -
Status- Forwarded By Institute Status Date- 13/01/2024
Maximum Marks(2021-22)- 500.00 Obtained Marks(2021-22)- 406.00
Result(2021-22)- PASS Attendance Percentage(2022-23)- 82.00 %