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Kerala Shops and Commercial Establishment Workers Welfare Fund Board (Website: www.peedika.kerala.gov.in)

tIcf tjm]vkv Bâv Itagvky FÌm_vfnjvsaâvkv sXmgnemfn

t£a\n[n t_mÀUv

APPLICATION FOR EDUCATIONAL SCHOLORSHIP hnZym`ymk kvtImfÀjn¸n\pÅ At]£

1. Name of Student/ hnZymÀ°nbpsS t]cv :

2. Address/taÂhnemkw :

3. Phone No./ t^m¬ \w. :

4. Male/Female / kv{Xo/]pcpj³ :

5. Name of the course applied for Scholorship/ kvtImfÀjn¸n\v th­n At]£n¡p¶ tImgvknsâ t]cv.

:

6. Details of examination passed / ]mkmbn«pÅ ]co£bpsS hniZmwiw.

Name of Exam ]co£bpsS t]cv

Name of affiliated University/Board

A^nentbäv sNbvXn«pÅ bqWnthgvknän/ t_mÀUv

Month and Year of passing examination

]co£ ]mkmb hÀjhpw amkhpw

7. Marks scored in the examination/ ]co£bv¡v hnZymÀ°n IcØam¡nb amÀ¡v. Subject Marks scored Maximum marks Percentage hnjbw IcØam¡nb

amÀ¡v IqSnb amÀ¡v iXam\w

BsI/Total

8.

Name of the parent of the applicant and Membership number / At]£Isâ AÑsâ /A½bpsS t]cpw AwKXz \¼cpw. (Photocopy of ID Card to be enclosed)

:

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9. Name and Address of the Establishment presently working and its Welfare Fund Registration No. / \nehn tPmen sNbvXp hcp¶ Øm]\ ¯nsâ t]cpw hnemkhpw t£a\n[nbnse cPnÌÀ \¼cpw.

:

The facts mentioned above are true to my knowledge. If I am selected for the

scholarship I promise that I will abide by the conditions stipulated in the scheme.

Cu At]£bn apIfn ]dªn«pÅ Imcy§Ä kXyamsW¶v Rm³ {]kvXmhn¡p¶p. Cu kvtImfÀjn¸n\v Rm³ XncsªSp¡s¸SpIbmsW¦n CXv kw_Ôn¨pÅ hyhØIfpw \n_Ô\Ifpw A\pkcn¨v s]cpamdmsa¶v CXn\m {]XnÚ sN¿p¶p.

Name and Signature of the Student hnZymÀ°nbpsS H¸pw t]cpw

Place/Øew: Date/XobXn:

Affidavit of the Parent c£IÀ¯mhnsâ kXy{]kvXmh\

I ……………………………………(Name and address) am a member of Kerala Shops and Commercial Establishments Workers Welfare Fund Board and my registration number is ………………………. Sri/Kum…………………………………… is my son/daughter. The facts mentioned in the application are true.

Rm³ …………………………………… (t]cpw taÂhnemkhpw) tIcf tjm]vkv Bâv Itagvky FÌm_vfnjvsaâvkv sXmgnemfn t£a\n[n t_mÀUnse …………………………………… \¼cpÅ AwKamWv. {io./Ipamcn. ……………………………………sâ aI\mWv/aIfmWv. Cu At]£bn ]dªn«pÅ Imcy§Ä kXyamWv.

Signature of the Parent. c£IÀ¯mhnsâ H¸v

Place/Øew: Date/XobXn:

At]£tbmsSm¸w lmPcmt¡­ tcJIÄ

1. Attested copy of SSLC Certificate. 2. Attested copy of Mark list of the qualifying exam. 3. Photocopy of Shop Board Membership Card.