Smt.Vijayalakshmi R.L.Jalappa Education Foundation (R.

)
No.185, Idiga Bhavan, Seshadripuram, Bangalore-560020
Web: www.jalappaedufoundation.org

SCHOLARSHIP APPLICATION FORM - 2023

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ONLINE REG.ID.NO: DVG10009482023

1. Applicant information
Name of the applicant Shreenivasa v
Present Address Line 1 Dental college road vidyanagara davanagere
Present Address Line 2 17th cross 5th main
District Davanagere
Taluk Davanagere
Pin Code : 577005
Giriyapura village hirekogalur post channagiri taluk davanagere
Permanent Address Line 1
dist
Permanent Address Line 2 Main road giriyapura
Native District Davanagere
Native Taluk Channagiri
Pin Code : 577552
Community : Idiga
Idiga/Sub Caste : Ediga
Date of Birth : 02-11-2001
Age : 21 Years,
Gender : Male
Mobile Number : 8296119688
SSLC Register No. : 20160737757
Email id : vshreenivas001@gmail.com
BPL card Number : 120100192559
Issued Authority :

.
2. Particulars of Applicants Parents:

Mother Name : ANJANAMMA

Mother Age : 49
Mother Occupation : LABOUR
Mother Annual Income : 30000
Mother Mobile Number : 8548831356

Father Name :
Father Age :
Father Occupation :
Father Annual Income :
Father Mobile Number :

3. Details of the College wherein the applicants has Studied

College Name : BRINDAVAN COLLEGE OF ENGINEERING
College Address : DWARAKANAGARA ,YELAHANKA,BANGALORE
Course Studying : M.C.A-2nd-yr
Academic Year : 2023-24
Fee paid receipt particulars :
Amount 150000
Receipt No. 950
Receipt Date 03-03-2023
Remarks :

4. Details of marks and percentage secured in the previous 3 years

(Photocopies of the marks card which should be attested by the Institution)
Course Institution Name Year Marks Percentage
B.Sc-2nd-yr GOVERMENT FIRST GRADE COLLEGE 2020 986 61
B.Sc-3rd-yr GOVERMENT FIRST GRADE COLLEGE 2021 1272 63
M.C.A-1st-yr BRINDAVAN COLLEGE OF ENGINEERING 2022 608 76
TOTAL 66.67

5. Particulars of Previous Scholarship availed :

Course Name Of Organization Year Amount Recived
6. Bank Particulars of student
Name Of Bank BANK OF INDIA
Branch KEMPANAHALLI
IFSC code BKID0008981
Account Number 898110110005365

I hereby declare the above statements are true and correct to best of my knowledge.

Student Signature Signature of the Father/Guardian

Place:______________
Seal and Signature
Date:______________ Head of the Institution/College

DOCUMENTS TO BE ATTACHED
The applicant should send the Printed application along with following documents (to be enclosed in the
following manner) to the address mentioned below by courier or by post.

1. Passport size photo.(affix to the application)

2. SSLC/10th, PUC/12thmarks card etc.
3. Previous 3 year marks card which should be duly attested by the Head of the Institute with seal.
4. Address proof and Identity proof pertaining to the applicant.(Adhar card)
5. BPL Card and Copy of Identity card issued by the institution.
6. Transfer certificate issued by the institution on completion of matriculation wherein the domicile and
caste status of the applicant is mentioned.
7. Fee paid receipt so as to avail admission to the current course being pursued by the applicant.
8. Copy of Student Bank Account passbook showing student photo and account number and IFSC code.

Address for sending filled in applications:

The Secretary
Smt.Vijayalakshmi R L Jalappa
Education foundation (Regd.)
No.126, Silver Star Hotel,
6th Cross, Gandhinagar,
Bangalore-560009