GOVERNMENT OF KARNATAKADIRECTORATE OF MINORITIES

PRE-MATRIC SCHOLARSHIP 2012-13 (FRESH & RENEWAL)(Ministry of Minority Affairs Govt. of India Scheme)

(IN CAPITAL LETTERS)

Did you receive the Pre-Matric Scholarship by the Directorate of Minorities during the year 2011-2012

For Students belonging to the Minority Communities - Muslims, Christians, Sikhs, Buddhists & Parsis

31st July 2012.

www.gokdom.com11th August 2012.

31st August 2012.

For students of 1 to 10 Standard only.

PART - I (TO BE FILLED BY THE CANDIDATE)

Full Name (in Block Letters as per school register)

Details of Parents/Guardian ( in Block letters)

School Address :

Academic & Fee Details

Pre-Matric Permanent ID Allotted :

st th

1. The students have to submit the filled in applications only to the Head Master / Principal of their respectiveschools on or before2. In turn the Head Masters/Principals have to submit the applications along with the list of the candidates inthe prescribed format available on the website to the concerned Block Educational Officer(B.E.O) on or before3. The Last date to submit the list of students (soft copy) by the concerned Block Educational Officer (B.E.O) tothe Directorate of Minorities is on or before

RENEWAL DETAILS

Yes ( ) No ( ). If yes, Amount Received : ________________.

10 digit

This ID has been allotted to all Fresh & Renewal students selected in the year 2011-12.If you do not know, please visit www.gokdom.com

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Affix recent colorpassport sizephotograph

(do not staple)

Father’s Name

Guardian’s Name

Father’s/Guardian’s Occupation

Annual Income of Parents/Guardian

Date of Birth(As per school records) Place of Birth Gender

(Mark by Tick)

Male ( ) Female ( )

Religion Nationality

PINCODE :

Name andaddress ofthe school

TALUK : DISTRICT :

Examination Passedduring 2011-12

Annual Fee for the year2012-13 (in Rs.)

TUITION FEE(a)

ADMISSION FEE(b)

TOTAL FEE(a+b)

Percentage of Marks Obtained Class Studying during 2012-13

Home Address: ( IN CAPITAL LETTERS)

Bank Details and Account Number of the Student:(Compulsory for Renewal cases/Optional for Fresh Applicants)

(i) Name of the student (as in the Bank Account) : _______________________________________________________

(iii) Bank Name : _______________________________________________________________________________________

(iv) Branch Name : _____________________________________________________________________________________

(1) Only Studentswho have scored not less than50% marks in the previous final examination may apply.(2) In case of 1stStandard students, 50%marks requirement will not apply. Only the incomecriteria will be

applicable.(3) The annual income of the student’s parents / guardian from all sources should not exceed Rs.1 lakh.

(i) Photo of the student must be pasted on the first page of this application.

(ii) Xerox Copy of the “ Caste & Income Certificate” issued by Tahsildar

(iii) Original Affidavit on non-judicial stamp paper of Rs.20/- as per the format given on Page 4 of this

Application

(i) I hereby declare that the information given above is correct.

(ii) I am not availing any other scholarship from any other source.

(iii) I shall abideby the termsand conditions for sanction of thePre-Matric Scholarship.

(iv) I undertake that if, at any stage, it is found to the satisfaction of the sanctioning authority in the State

Government that the information given by me is false or if I violate the terms and conditions of the scholarship,

the scholarship sanctioned to me, may be cancelled and the entire amount of scholarship will be refunded by

meor recovered fromme,apart from suchpenal action as warranted by law.

Signature/Thumb impression of Signature of the studentParent/guardian

Place : _________________________

Date :

(v) IFSC Code :

or

(iv) For Renewal Students only - Xerox Copy of the Pass Book (First Page) or any document from the bank

carrying the Account No. Of the student, Student Name, Bank Name and Branch Address.

(ii) Saving's Account Number :

_________________________

Please enter the complete 12 or 14 or 16 digit Account No. in the above box

Please enter all 11 digits correctly. Contactthe Bank Manager for the IFSC Code.

Note : If you are opening a new bank account to fill the above details, make sure that the Bank has an IFSCcode and then open the bank account. Generally all Nationalized banks have an IFSC Code.

CONDITIONS

Documents to be enclosed (attached) with the application

DECLARATION

PINCODE : TALUK : DISTRICT :

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PART - II [ TO BE FILLED UP BY THE HEAD MASTER / PRINCIPAL OF THE SCHOOL ]

Verification/information to be furnished by the Head Master / Principal of the School

2012-2013

(i) It is certified that the information filled in the above mentioned columns by

Shri/Kumari ___________________________________________________________________________________________

son/daughter of _______________________________________________________________________________________

who is studying in _____________ standard for the academic year in our school is correct.

(ii) He/She has secured ____________ percentage of marks in the previous annual examination.

I have scrutinized the documents and verified with the school records and certify that the

information furnished above is correct and true to the best of my knowledge, and confirm that no student

of other caste other than the above said minority communities is recommended for this scholarship.

Date : ____________________ Signature of the Head Master/Principal of the schoolWith official seal having the complete address

Place : ____________________ of the school

1. If you have the “Caste & Income certificate issued by Tahsildar”, you can attach a Xeroxcopy of it attested by a azetted officer along with the application form.

2. If you do not have the “Caste & Income certificate issued by Tahsildar” , then type the matter given inPage No.4, ona non-judicial stamp paper of Rs.20/- and get it attested by a Public Notary and attach

original to this application.

IMPORTANT NOTE:-

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the

3. DO NOT attach any Original or Xerox Copy of Marks Cardor Address Proof documents withthis application.

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AFFIDAVIT FORMAT(To be typed on a Non-Judicial Stamp Paper of Rs.20/- and notarized

by Public Notary with Seal & Signature )

DECLARATION OF PARENTS'/GUARDIAN'S ANNUAL INCOME &MINORITY COMMUNITY

I ……...……………………....……………………….………………………............(Father/Mother/Guardian)

Of ………....……………………………………………….................……...........….…(Name ofStudent) who

is studying in …….................……… Standard hereby declare that myannual income from all sources

is Rs…………....…... (in figures) Rupees……………………..……………………………….…….……only.

I declare that I belong to ………………………………..... (Muslim/Christian/Sikh/Buddhist/Parsis)community.

If at any stage, it is found that the information given by me is false/not true, all benefits given to

the student under the scheme of

could be withdrawn and legal action as deemed fit, maybe taken against me or myWard.

Date : _______________ Signature(Father/Mother/Guardian)

Place : _______________

Address :

__________________________________________

__________________________________________

__________________________________________

“Pre-Matric scholarship for students belonging to MinorityCommunities”