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

Session - (2023-24)
(To be submitted to the educational institution)
Print date:- 26/12/2023
Registration Details
District Name: KHERI
Name of educational institution: CHAUDHARY INSTITUTE OF PHARMACEUTICAL SCIENCE
Registration Number: 231110102100224
Name of the student: VEERENDRA KUMAR
If the changed name of the
student is:

Father's / Husband's name: NEVRATAN

mother's name: RAM DEVI
Religion: Hindu
Other Backward Classes (except Minority
Class/Caste Group:
Backward Classes)
date of birth: 21/03/1997
gender: MALE
Mobile, Telephone No .: XXXXXX2312 ,
E-mail
high school board up board year of high school graduation 2016
High School Board Roll Name and address of the university/institution CH LTSDPIC MUSALLAMPUR
2428932
Number from where you have passed high school BAHARAICH

Academic Details
1-Course Name:
2-Branch of course: BACHELOR OF PHARMACY
3-Type of course: self financed 4-Class year and duration: 3,4
5-Entry is based on lateral entry NO 6-Residential/Day Students: Day scholar
7-Date of admission in the first 8-Date of admission in the
11/11/2021 01/09/2023
year of the course: current session of the course:
9-Registration number in 10-Name of the
UP Technical University,
University/Board/Affiliating 211136050085014 University/Board/Affiliating
Lucknow
Agency Agency:
11-Is admission to professional
course based on class 12 YES 12-Course Eligibility: intermediate
marks/merit:
13-Whether admission to the
current course is through
NO 14-Entrance Exam Type
entrance examination through
(UPSEE(AKTU)/JEECUP/NEET)
15-Counselling Number 16-Entrance Exam Year Sele
17-Rank obtained in entrance 18-Cut-off marks obtained in
examination entrance examination
19- Details of educational qualification (high school and other higher classes) for the last years
Name of the
serial
educational qualification passed year Integer score Percent Board/University/Affiliating
number
Agency
 personal details
20-Sub caste: LODH
21-Residential permanent
VILL MAILA MAJRA KALUWAPUR - POST SISAIYA KALAN KHERI
address:
22-Correspondence address : VILL MAILA MAJRA KALUWAPUR - POST SISAIYA KALAN KHERI
23- Ration Card Number/Family
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 235203006269 27-Date of issue of caste certificate: 28/10/2020
28-Caste Certificate Application Form No: 201530030112287
29-Income of the student's family from all Annually
30-Income Certificate No. 235201020893
sources (Rs.): 46000
31-Date of issue of income certificate: 02/11/2020 32-Income Certificate Application Form No.: 201530010203750

bank details
33-Name of the bank: India Post Payments 34- Name of the district:
Kheri
(where the student has an account) Bank (where the student has the account)

36-Bank account number of the

35-Branch Name: LAKHIMPUR KHERI XXXXXXXXX4337
student:
38- Name mentioned on the
37-IFS Code: IPOS0000001 VEERENDRA KUMAR
student's bank account:

Fee related details

39(i)-Approved Annual Non-Refundable Compulsory Fee: 63300

last year details

(ii)-Previous year's examination
40(i)-Last year's exam result: PASS semester system
system:
Annual Exam Marking
(iii)-Last year's marking system:
System
(iv)-integer of last year 1450.00 (v)- Last year's marks 1052.00
(vii)-Name of the educational Chaudhary institute of
(vi)-Percentage of last year 72.55
institution pharmaceutical science

Form Submission Date:- 26/12/2023

manifes to D938525D0C30D3AA38F54C6F3A67E005

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 in service, then 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/O BC/Minority Departments to obtain my Aadhaar number and Demographic/OTP for Authentication with UIDAI.
SUB-AUA (SW/ST/O BC/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/G en/O BC/Min Scholarship benefits.
I give my consent for demographic and OTP authentication with the Unique Identification Authority of India by obtaining my Aadhaar number from the concerned departments for
the scholarship of Scheduled Caste/Scheduled Tribe/G eneral Class/Backward Class/Minority. 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) - Class - - Category - Other Backward Classes (except

Minority Backward Classes)
Appendix – 'Ch'
Registration Number:- 231110102100224
D938525D0C30D3AA38F54C6F3A67E005

Receipt of application form for Dashmottara scholarship and fee reimbursement

Mr./Mrs./Ms. VEERENDRA KUMAR Son/Daughter/Wife of Mr. NEVRATAN
Institute CHAUDHARY INSTITUTE OF PHARMACEUTICAL SCIENCE Syllabus
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.