GOVERNMENT OF ARUNACHAL PRADESH DIRECTORATE OF HIGHER & TECHNICAL EDUCATION ITANAGAR. FORM OF APPLICATION FOR N.E.C. STIPEND OF APST CANDIDATES FOR THE ESSION 2009-10. ( Fresh ) FORM NO.......( To be filled up in the Directorate ) SUBJECT OF STUDY:............................ CODE NO............(Refer code list) LEVEL OF STUDY Ph.D./P.G./DIPLOMA/DEGREE/DIPLOMA (1) (2) (3) (4) (5) 1. Name of the candidate :.................. (In block letters) 2. (a) Name of the father/guardian :.................. (b) Occupation of parent/guardian:.................. (c) Parent/guardian Annual income:................... 3. Permanent residential Address :.................. Town/Village :.................. State :................... Pin Code : ................... 4. Address for correspondence :................... State :................... Pin Code : ................... Contact No. (if any) :............ 5. (a) Name of the course in which the candidate has been admitted. (In :................... words as well as code Nos. if any (Refer to Annexure I to III for code) (b) Perentage of marks obtained qualifying:examination (Class X/10+2/Degree/PG) (Attested copy of the mark sheets should be attached). Grade points should be converted to percentage. (c) Minimum qualification required for :admission in the course. 6. Duration of the course. : 7. Full address of the University/Institution :where candidate has been admitted. (In block letter) Address : .............. City :.............. State :.............. Pin Code:............. P.T.O. -2 8. Date of admission :-............. 9. Date of commencement of session :-............. 10. Expected date of completion course :-............. 11. Whether already in receipt of any Stipend/Scholarship etc. and if so, the:-...(Y/N) 1) for Yes rate and Source (undertaking at 2) for No Annexure 'A' to be furnished) 12. Whether belongs to APST, if so, :-.............. attached copy of certificate 13. Name of the State to which the Candidate belongs. Enclosed attested :............. copy of permanent Residential certificate issued by the Competent Authority at Annexure-B. 14. Whether an undertaking has been :... ..1) for Yes furnished in the enclosed form 2) for No (Annexure-C) to serve at any place in the North Eastern Region on successfull completion of the course if any 15. Whether an undertaking has been furnished : .....1) for Yes in the enclosed form (Annexure-D) for returning 2) for No the stipend/book-grant received from NEC in case of terms and conditions of NEC stipend. 16. Declaration by the Applicant: I do hereby declare that the particulars furnished by me in this application form have been filled in by me in own handwriting and are correct and complete to the best of my knowledge and belief and I have not concealed my fact or furnished any false information which will render my application liable to be summarly rejected. I also hereby declare that I shall not avail myself of two stipend/scholarship simultaneously from two sources . I shall forego the stipend/scholarship granted in favour of me by any authority other than NEC and State/National merit scholarship from the period when I would be granted the NEC stipend & book grant. Date : ..... Place:..... Signature of the candidate P.T.O. -3- RECOMMEDATION BY HEAD OF INSTITUTION (Note: Candidate should not write anything in this section) Recommended for N.E.C. stipend/book-grant. This applicant Shri/Smti/Kum....... ...............course (specify subject )at ........... ........(name of the institute) which is/is not recognized by the ATCTE/any other similar central/state Govt.organisation. A copy of the recognition letter is enclosed herewith. The date of admission is ........ The date of commencement ........ The date of completion of course is ......... Designation of the Drawing and Disbursing Authority of the institute to whom Draft is to be dispatched by the N.E.C in favour of .............. .................................... SBI Code No. (Draft shall be drawn at SBI only) :................ SEAL OF THE INSTITUTE (signature) Principal/Registrar/Dean or any other Officer Authorized to recommend and certify. .................................... (ANNEXURE-A) I hereby declare that I have not availed and shall not avail myself any stipend/scholarships etc, from any other source. I shall forego the stipend/scholarship granted in favour of me by any Authority other than NEC except as permissible under the Rules from the period from when I would be granted the NEC stipend and book grant. (Signature and full name of the candidate ) (ANNEXURE-B) PERMANENT RESIDENTIAL CERTIFICATE This is to certify that Shri/Smti/Kum................... Son/daughter/wife of Shri........................... Village/town .................Post Office .......... Police Station.........District................is a Permanent resident in the District......... in the State of .......... ............... This PRC is for higher study purpose only. Date: ....... ( Signature of the Deputy Commissioner) Place:...... District...... SEAL P.T.O. -4 (ANNEXURE-C) I here give an undertaking that I shall serve at any place in the North Eastern Region on successful completion of the course for a minimum period of 5(Five) years, If any opportunity arises. N.E.C. will not have any liability to provide any job to me. (signature and full name of the candidate) (ANNEXURE-D) We hereby give an undertaking that in the event of committing breach of terms and conditions of N.E.C.stipend /bookgrant and if any information given by the candidate is found to be false the whole of the amount given to the student shall become payable jointy or severally by the student and the surety. (Full Name of the parent/Gurdian) (signature of lst witness) Name (in capital letters) Address in full (signature of the student) Date.. (signature of 2nd witness) Name(in capital letters) (Signature of the Surety) Date: th Note:-The last date of submission is 16November 2009.
