GOVERNMENT OF MIZORAM SCIENCE, TECHNOLOGY & ENVIRONMENT CELL PLANNING DEPARTMENT *** APPLICATION FORM FOR AWARD OF MIZORAM POST MATRIC MERIT SCIENCE SCHOLARSHIP, 2005 -2006 PART 'A' (To be filled in the applicant) 1. Name in full ___________________________________________ (in block capital letters) 2. Father's Name & Address __________________________________________ 3. Permanent Address __________________________________________ (Residential certificate from the President, village council __________________________________________ as per Performa enclosed must be attached) 4. Present Address __________________________________________ 5. Guardian's Name & Address __________________________________________ (If differs from Sl.No 4) 6. Institution where studying now _________________________________________ 7. Class/Year __________________________________________ Roll No _________________________________________ Date of Admission _________________________________________ Date of joining Class __________________________________________ Subject Combination 1. Major Subject _____________________________ 2. Others i)_____________________________ ii)_____________________________ iii)____________________________ iv)_____________________________ v)_____________________________ 8. Particulars of the last examination taken by the Student 1. Name of Examination __________________________________________ 2. Whether Univ/Board/Promotion Exam _______________________________ 3. Year __________________________________________ 4. Marks Obtained SUBJECT/PAPER FULL MARKS/MARKS PERCENTAGE OBTAINED OF MARKS OBTAINED 1._____________ ___________________ _________________ 2._____________ ___________________ _________________ 3._____________ ___________________ _________________ 4._____________ ____________________ _________________ 5.____________ ____________________ ________________ (Attested copies of Mark sheets of last examination should be attached) I hereby certify that the statements made in this application are correct. I further undertake to refund to the authority on demand the entire amount of Scholarship received by me if- 1) I discontinue the course for which the Scholarship is awarded to me for any reason. 2) I switch over to the course other than for the scholarship is awarded for me. 3) I draw scholarship from other source for the same course of study. Dated______________________ The _______________________ (Signature of applicant) PART'B' (To be filled in by the head of Institution) 1. Certified that the information given by the applicant in part'A' has been checked and are correct to the best of my knowledge and that this institution is affiliated to the ____________________________ (name of Univ/Board)University/Board recognized by the Govt. of India/State Govt. of________________________ 2. Character, Conduct and attendance of the applicant:_____________________ 3. Date of commencement of the current academic session:_________________ 4. Likely date on which the current session will be over:___________________ 5. Is the applicant exempted from payment of fees? If yes, please indicate whether the exemption is full or half: _______________________________ 6. The student is required to pay the following fees to this institution for the current year 2002-2003 Particular Rate Amount actual payable Remarks to the Institution 1.Registration fee 2.Tuition fee 3.Library fee 4.Game fee 5.Union fee 6.Magazine fee 7.Medical fee 8.Examination fee 9.Laboratory fee 10.Other(Please specify) Totals fees payable _____________________________________________________________________ Date______________________ (Office Seal) Signature of the Head of Institution with seal ......... RESIDENTIAL CERTIFICATE Pi/Pu/Nl/Tv __________________________________________________ Pa hming____________________________ hi kan Village Council huam chhunga In leh Lo neia khawsa nghet a ni e. (VCP hmingziak leh Seal)
