applicationform for adw scholarship scheme-2020-2021

APPLICATIONFORM FOR ADW SCHOLARSHIP SCHEME-2020-2021 INSTITUTION NAME : MADURAI KAMARAJ UNIVERSITY

Academic Year

Course

Year

Studying Course Type Self Support/ Regular Lateral Entry Yes/ No

Date of Admission

(dd-mm-yyy)

Student Unique ID

Student Reg. No. (Given by Institution)

Name of the Applicant Mother Name:

Parent/ Guardian Name Occupation

Date of Bith (dd-mm-yyyy) Gender

Community Caste

Annual Family Incomme

(Income certificate period should not exceed 6 months at the time of admission)

Admission Mode Government/ Payment First Graduate Availed: Yes/No

10 Register No : 12th Register No:

E-mail Address Mobile No.

Bank Account No. Bank Namne

Bank Address

IFSC Code MICR Code (3Digit (City Code)+3 Digit (Bank Code) +2 Digit (Branch Code)}

eg. 600002068 for SBI Avadi Chennai)

Aadhaar Nol Aadhar Enrolment Id no Enrolment date/time

Address for Correspondence: Permanent Address

District: Distriet:

Taluk Taluk:

Pin code Pin code:

Hosteller Yes No

Paid Hostel Free Hostel Hostel name

Date of Joining :

Date of Leaving:

M.uJ5. 73

GOVERNMENT Or TAMIL NADU

QKSosLi unpud uyprivgip uîlori pavhgisnm ADI DRAVIDAR AND TRIBAL WELFARE DEPARTMENT

UigULlbgtlu n.golgGlgrms Gugingmamo ol6o0T 600T Úuh. FORM To APPLY FOR THE GRANT OF GOVERNMENT OF INDIA/

STATE GOVERNMENT POST MATRIC SCHOLARSHIPS

FRESH FORM

Name of the institution

LOT6a0T 6f lsor

Academic Year BGuTmg5w

6m 630TL LwSTT LITl¡ 6) LDITSOOTOJG

59565UuLL 25LUuTST 6T600T Scholarship Student Id Generated in Online: (To be filled by the institution)

Gousor Gu.

LpT600T 6 Guui (Glz6rflauT 6OT 6T(LR}EIEa6flsb) Full Name of the Student (in Block

letters)

Lylsd

English

2 uTserin/ Gender (46 vGouwah)

1.jain Male O: 2.uoOT/Female 3.igpmá unadloamh / Transgender piso GosI Date of Birth

GupGpi 20gi uTgjsrouOvrr olauyú / Parent or Guardian Details (Guppi 9l6v6nau 6rGotl6d LuTgjBTOJOUÍ 6Sl6uu GpiiLÜuL Gaus0T (GLi)

Bm Guur / Name of the Mother

4

5png Qluui /Name of the Father

ungjUTJaur Gluwui /Name of the Guardian

en ohlouno / Cornmunity Details:

(a) uyu ungsoni (SC) (b) upruy uflsoni(ST)

5

Scheduled Caste Converted

Lo Christianity (SCC) an 2iiSflns Gluw / Sub custe Namne

s0/12 .u.p.73-2,47,800 Cps.-2019-.MUBs

Scanned with CamScanner

2

GLumGpni 94mhi Lmghil) nni alnyfho Parent or Guardian Occupation

uTghIT616i

616ls, ugoililsor Gluui, usoflyfluih olu. If the student's

nfhuri

Parent/Guardian is working in Govt of India / Statc Govt Private Sector, Designation and Office details.

usTmffluu wb$lu 9/Th LDrißlau 91ag6ofluumii

BpiumLLÍ GSI emsorpslv GpusLGloiroT UGLDToOTÉh SD 5 6Tg5 Gausrimlb. (omwésnsng Bss gomseoT 66ÚIL

Gaus) Income as per Salary Certificate

obtained from the Govt of' India / State Govt Private Organisation (Salary

Certificate is to be enclosed)

GlumuuLL 6UGLoT6OT

hu 2sToTugLOTSOTLD Family Annual

Income (LLTLu oupichuu

ensolsou sÚLLGoiroT GoT S0T55n5 ST GaoTGlua.)

GLoTSOT

Giy Note: gu6O0TLOIT DT GLuTOT d0T 60TULISTJT STGat lao, s00T t lsar (aluurfla GupúuLL aGLoTGOTÖ

asip oLGGo l6n6o0T 666LILL Gouoöor (6ln. Married women applicants should enclose income

certificate of their husband. 8

Permanent Address with Postal Pincode Temporary Address with Postal Pincode

9

Student's Audhaar Number

LDI GO1u vaug GluibGpufloan G\gircvaGudl 1601/Student's or Parent's Phone Number

10

--

Student's e-mail id

so/12 up 73-u


B97 ig 6 om6BT)a nbo neapuh ,Aor / Class of Study in Current Yeur

(c) III Ycar (a) I Year (b) I1 Ycar

(0VI Ycar (d) IV Year (c) V Ycar

LDr SDT U uslgyà unuobhor alhuui uongyub SMoilodr

13 uuwi Course&Subject of Study of the

applicant (Examble:

Subject Tamil) 1unsbssaDv sUGUY / Higher Secondary

Class(+1or+2),Maths Biology, Commerce

Computer, History, etc.)

Main su bject

pho0T 60LDÚ UITLÜUrfls Course Name

Course B.A.,

21@mSlsmsuÙ ULLÜUg Üy/U.G. Degree Course. Eg. B.A.,(tamii) B.Sc., ( Maths)

etc3)Smwù uLL GupuigÜy / P.G./ Research

Course Eg, M.A.. (Tamil) M.Sc., (Maths),

M.Phil..(Tamil/ Maths) P.hD., etc. 4)oSTlmuigUy/ Professi1onal Course

Eg.B.E..M.E. ,B.L. ,M.L. ,M.B.B.S.,B.D.S.,

Sc,.Nursing), C.A., etc.. 5JULLIULgUY Diploma Course

Eg. D.E.C.E., D E.E.E..ctc 6 ETS0TD5Y LigUY/ Certificate Course

Gsuso Guo / Duraion of Course should be

atleast one year)_ E6u Luigyn u6np/Category of Study

14

1 juss Gpo/ Day Time

2J om smau Gpnin /Evening Time

3)uIG GpT /Part Time

4)Glgm6n6)gTgu /Correspondence oTGOOT6T Uuslgyyo LIgulo1 GlorDH dIT SN6104

Duration of the course pursued by the 15

student

oT601 u LughgTiD 6uGúy Glungs Gyioilu Ggiiósl Glupp 2601 ugjlo 6160r Year and

Register number of Passing 10 Public

Examinalion.

l6 Year Registration No._

LoT601 6u U6fGlg sooiiII Ongin Glun giy Ggiiolou

Goios Gupp o0n0 ueßay s160 Ycar and

Register number of Pass1ng 12 Public Examination.

Luhlo 61601.

Registration No. Year


uloy 6s1sor.

18 uy so.. Year and Register numnber of

Passing Diplamo Public Examination.

Year Registralion No.

19 LoITS07 6ai Lnílguyun (ysmp Category of Study (4, v Gauuni)

A) aGSuslsv ysvsuru GupGm B) s0ulao g5t6efl Luslveuri

Hostellcr

Luslvunui / Day Scholar

20 uggmu avGÜyIGÚ SsOI60uri uslsarm LlgÚYGsrfls0T slaub/ GlumiuLL hsva a 5alglgnsn silsum

s gdgu DGuSs0r 915s01 6loun. Details of postmatric Courses after X standard in

which applicant studied - Scholarship Details / If break of study details should be

furnished.

UuslsT ST0T(G Lomp UigUy slsumh / Details

of study undergone together with year

of study

GlumüuLL 60al

GlumuuLLsT/ Whether

obtained Scholarship Yes No)

Gluwi Name of Amount of the instütution Scholarship received

21 ,6DGI 86vilursoOT Gl%6flsu onoT66T UuSsTm JGUYSflsu

u 25lgagnma, Gluppauyn ? (ayi sTsaflsù Gmpamoa uLIGT BGD

hLLosls

6Lso 6606nsco 66RIUL GousdoGuo) Whether the applicant is in receipt of more than two scholarship including this one? If yes, he should retum the scholarship to Govt., which is less beneficial to him as per his choice and

chellan copy should be enclosed. (i) Glsgusgó6Lyo0r 61600 LDbgI sM6

Challen Number and Dale

22 LDITSOOTIT É E6 GumsL Gni flá6sual

olau.Whether the student has applied for any other scholarship scheme other than this scheme? If, yes provide the details of the schemc


6LDIJTSTL sL koiji,g nn annd0ii Glamlhnia thoinll ibpyauurenoaf lov

uuslabumn?

23

n sTtleiv a fhuu ommuh aprsngh 1ponrghgpmA uprsesLuLL

hLLMURNTa 0rhoiuL Gaedo Oto. Whehter the student

belongs to the domicile state of Tamilnadu and studying in other stales? 1f yes, cnclosc Insitution's latest approval

and afliliation orders issued by the appropriate authority LoTSODT 6If lsö1 uriekl a600T ( Dlouno / Student Bank Account Details

1Ruriuler Guui/ Name of the Bank

24

Name of the Branch

3

Bank Account Number 4 MICR Code of the Bank /auruíleoT

s5mLD STLg`GIG (GIlusG 5 IFSC Code / aurielsofler gbSu B

6LDLILY GMuSO

DECLARATION

1) sriTSDOTUILISSGo G ÚuLOaimoT 91m6T DSI ol6ouyrusT, eflusmsnau

2smLLTm6DUST 2gysualéAGps. oT6Tem afsaiuLL GuhosinL lnujtssiT lsroamonai

TLS ufuigy SIguS SHafiss GensAGpsr smeT LDRmLDTy p fài@pein. I here by declare that all the details submitted application are correct and true. If any of the details submitted is found to be incorrect later, then I here by give my consent to return the scholarship to

sanctioned to Government in any means prescribed by the Govermment. 2) BLUy 80alumsTIpu Gunsiv GuuLfó asvsl a50haznmssg oladrsoTLuslssi ss

Lngu Iungleu Góni 2.50lgagnsneh hLLrea lsr gb. uwcrGlup olsimsroriiSulzUSs,

2uaflsIper. In the event that If, I had / have applied for Post-matric scholarship and

any other schemes of Central / State Govt. in current year / previous year and if i am /was the student is selected for the award of scholarship in more than one scheme then I here by give my con sent to return the scholarships under the schemes to Government and retan one scholarship of higher benefit as per my choice

LoT6OBT U/un 6oo1 olurfis0T 6umÚuub

Signature of Student

GupSpmi / ungiømaaurflsr smsalumÜLD Signature of parent /Guardian

Place Date


Additional benefits for physically dlisabled SC/ST sluudents under Govt. of India

Postmatlric Scholurship beneliciaries alone.

Gleuves/whethcr the applicant of physically dlisabled If yes, tick ( v ) the suitable.

1 umi Sió Gmps/ Low Vision

2 omg GaL ul Gsmysnmout/ Deaf

3 GlgnGipTuSlsb QGbgI Ss0oTLui soiT / Recovered from leprosy

LD6OTTUTsU uIT$ÜuSLDGOUTOb6iT/ Psychologically affected. 4

5 5lusoT &6ugunflág Gudusui/ Orthopedically

handicapped gOing to college with the help ol an escort.

BreluGÜuauiGsT / Physically handidcapped students

staying in hostels attached to the Institution CLDsm6T 6u6TT 6) G60TuauTB,EBIT 6OT nuy uuílmá Glumjuaut&ST/Special coaching for mentally retarded

person. GLnGuuflsma 61600T (5) 5ULLGlsr6T ulsgi0m soT uT6TIT EB6ÍT 25luL60 56ugrflag

8

6lgID 600T LUT 6TT flsor (olLuwr LommjiD (Lp56url/ Escort Name and Address

IyuurflBiI encoolsip lubgi glsmoot ós GasoD. For the disabilities listed above,

Certificate issued by the Competant medical authority should be obtaincd and

enclosed with the application.

auyflbgj6v6oaTIIT 6Tl69r 6e5 GluTULIb/ Escort Signature


bal mauu gmnnd fompaj aauuuÚIL Gai0Tip ILU TO BE FILLED BY THE HEAD OF TIE INSTITUTION

hDl Bpsusmh Se 88un/Classificalion of the Institution ip » ( ) aauinuajo.

a)Central Governnment b) State CGovernment

c) Government aided d) Self inance/ Private

66US1sdauwsm Guui opgu ygsmLDLwT6OT (LD5Jfl (g6hssv GDlULGL60r) Name of the Institute and Address with Pincode

3

c-mail id of the Insitution 5U6 l6usvuwGSls07 GlgT6DvGuá sTsooi.

1)Phone Number of the institution

2) Mobile Number of the person dealing with

Scholarship subject

4

on 6oOTT E6l Gluuri/Student Name

LoToDUTT&i BjtungI 660al Uulayub hanluT 6O0T(B Academic Year in which the student is

6

studing on current year uITLULSIflail6or GluuT /Subject Name 7

p&uTg LILSlgyio LlgUÚ LiIflailsv uuslguh suGLO

Studying Year of the Course 8

9 uo6o Student Register Number assigned

by the Institution 10 9T8 6250 GlugiD a.6ugyfl 6160f16i, LoT60DT6UT

uslgyo uTLUSMlD4 ST6 2 Ho Glumu unLÚSlflaur (9)

a 5y LITLULSfloun/ If the Institution Govt. /

Govt.aided whether the course pursued by the student is a Regular Course or Self

Support Course 11

@HILKLys 6 Goi ósne, Gupmauyn ?

/Mode of Admission whether Government Quota (or) Management Quota ?


ITT/Date in which the applicant joined the

class n current year 13 i L6nTig oi Ghgbio upig uph unbd

Month n which the annual examination in

Curren Vear will be over 14 uDoi sGdlSv ghriddii uladn us ma?

Where the applicant is residing in the Hostel?

eShdledr Ghuui/ Name of the Hostel

LOn SO8TuT GSuilso Goni,s gloir.

Date on which the student joined the

hostel

Where the hostel is attached to the

institution?

5m nsu JràiisflssuLLG? lf private Hostel whether it is recognized by

education institution Head. 55of lumT oi05lur? 2600T , 26plLg6b5

ELLGOOT iD goléscsiuGAipsT? svnug labuGLoT 6 uprivaÚuGlpsr ?Whether the

Hostel is run by the Private management and whether free boarding and lodging

is provided. A 0ur? s1dflb, silauyesT a.s.ah/ Whether the student is staying in the Govt. Hostel,If so, indicate details there for. (i)

Adi-Dravidar Welfare Department Hostel

15

11 Backward Class Wclfare Department Hostel

(iii) Lbls60qD LSlHuOogÜuL GLr Lomgiuh SmunsT 5DulsoTiT augImp oG/ Most Backward Class and

Minorities Welfare Department Hostel 5 oGßsT GuSLah/Other hostels

(iv) please indicate

16 olG omÚuTOTfloor Guui upg 60GunÚL wblouL6OT/Name and Signature of the Warden

and Seal

17 Ib50)w Buveiluin voorly i LoT60r 61Ii al sbgyioirGI 6ULOMU

olgóenPercentage of Alendance oblaincd by he student in last year.


6sUe enwuo p¬nunufler 2pIGGungl DECLARATION OF HEAD OF THE INSTITUTiON

6pen. Ceruficd that, the student has secured rcguisite pe7UEn tae attendance for sanction of scholarship.

sSreih,

* CeciarC that documents submitted by ihe students wil be proeucet C: ALC

conducted by the Central Govermment StatE Go:ernTEn

SS subs¬pi. The details submitted by the sudent in his applicaton ar

Teriied and post maric scholarship has been claimed based on tose verinec

Cetals. f it is iound that scholarship nas been claimed bv instimion bF SuOtn

ncorect data scholarship obtained so vl be rerurned to gOvernmen: accont

he m2nner as prescribed by the government

m feáipr.If the student has applied for more than one scheme including this

scheme and if the student is selected for he award of scholarship under nore than

one scheme then as per the choice exercised by the student. scholarship beneft

under he schemes uill be remitted to GovTmment account by recovering he stude

Place Principal Signature with Seal

Date


10

ofumnny uLIg IUu /CHECK LIST

2.anu 18mbgpid @güsloin pog unsarblb /Break Certificate

Passport size photo

3.8nl un1p Community Certificate

Mark Certificate

5.0uLDIT60T eT601 Income Certificate

Bank Pass Book First Page Copy.

8.95m 6160T 6T6T

Aadhaar Card Copy 7.6usMhd ønsormI Attendance Certiñcate

10.Qum@pmi / ungsTOU6U 60LDu

T LomBlou TE 560flwmT

Blmisusor BlmyoublLL(GLSI

$l T6TmI g%6i Incone as

9.DpL 6L Geis 6760f16u,

Bmasatrh&afli uulsiuiT 6T6ofla

Bpiu ensg. Whehter the student

belongs to the domicile

state of Tamilnadu and

9mLlLuIT GupuuLL

Salary Certificate per obtained from the Govt. of

India / State Govt. / Private

Organisation Certificate is to be enclosed)

studying in other states? If

yes, enclose Insitution's (Salary

latest apPproval copy.

25gGgTsmw 6áG BgÜN Gagu~sugpEITT leguigië ALO 5su. If the

student is in receipt of Scholarship under more than one Scheme in

the previous year than challan copy for the remittance of scholarship

received under the scheme where the benefit is less as per the choice

exercised by the student to the government.

Gpiy-() Brhi6s6Tgj ssvbl a.5015olgT60m5 6Ml6o016anTLU5jms0r Q551mpuT sTrlssiT LIuslgu uoiTafl 6óvgynflág uprvestL LL g60500T ui uusOTi (GpSO (Login ID)

uudnuTi uGaubpù Geigi outúsboiu@th. Sunmg ahu sravásis) guss uligynà

Loiarfl/ sóvgynfl (ypauon gB61 oilaorsoTLLI5%6ms0r gonsTU OMuslv uhGoummù laial aisT,élscm s 9U DLLUreT GLO STT (Scholarship Student ID)

GEII éeiasin gisøong Student id yauLD 6U 2.5illgnsns olsaT6oUT ÚugloT

sm 600T Ig6TLPGUitl: hilps., dpl..dw sulholiirship.tn.gov.n/edst adw


MADURAI KAMARAJ UNIVERSITY

Application form for tuítion fee concession under 92 of Tamilnadu

Educational Rules for the year (Fresh/ Renewal) 200 200

. Name of the School / Deparimeni

Name of the student (!N CAPrCAL LATTERs)

3. Course of Study

4. Sex Religlon

5. Name and occupalion of the Parent / Guardian ...

6. Anoual Income of the Pareat/ Guardian

7. Preseat Adtress

8. Permanent Address

9 Whe:her belongs to BC SC ST MBC

DNT etc. (Community and Income certif+cares

should be egcloscd io the preseribed. form

(Form No. 18 under 92 ef Tamilaadu

Educational Rvies)|

10. If so, State Sub-Cast«

Charactr and conduct of the staceat

(General Review)

2. Nature of the fee concession a1aitd durivg

he last year

13. Specific recomaendatiors o thc Principal /

Head of the Iastirution Department etc.

for contio uation of fee contession under

92 of Tamilnadu Edueaionà! Rties lor

he year 200

14. Remarks if scy

Sigrature of ihe student.

Daie Couniersiznature of the

Principal 1'aad of the Instltution

Departmen Sehcal with Offlce Seai

oie a ca of First year stvdenis, the countersignature of the Peincipal (whero

he sIudent undergoce bis| ter previous course of study) should be obtuiued

MADURAI KAMARAJ UNIVERSITY Undertaking form to be given by the student, parent and duly countersigned by the Professor & Head of the Department

S/o. D/o.

Thiru/Tmt /Selvi- seeking admission to

(Class) in the MADURAIKAMARAJ UNIVERSITY

during the year 20 -20 without prepaymnent of Special fees etc., in anticipation of

sanction of Government of India/ State Scholarship to SC/ST/ SC converted to Christianity. I am fully aware that the grant of scholarship to me is subject to the condition

that I should be studious and disciplined and should put not less than 75% attendance from

the date of admission both during the previous year and the present period of my studies

with a provision of condone the short fall of attendance upto 64% for genuine cases without

charging any condonation fee. I am also given to understand that if I fail to show 75%

attendance during the priod of my study. I shall become ineligible for the scholarship, if any sanctioned, shall be cancelled and recovered from me and that the grant of rene wal of

scholarship for my further studies shall be stopped. In case of cancellation of scholarship, I

undertake to pay my dues to the institution and Hostel from my own sources.

1. Signature of the Student with date. (Name and class of the student)

2. Signature of the Parent/Guardian with date.

Countersignature of the Professor & Head of the Department School with Office seal.

3.

applicationform for adw scholarship scheme-2020-2021

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