2021-22

C.K.K. Pillai.

Diwan Bahadur Subburayalu

Reddy.

O.S.Gangadaran Pillai.

P.Rajamannar Chetty.

T.Venkatasubramaniam.
/
(Technical Education
only)

27.10.2022

Ph.No. 044-2534 2278

 Application. No:
APPLICATION FORM

AWARD OF SCHOLARSHIP FOR THE YEAR 2021-22

(For office use only)

Not to be filled in by the student:

Last date of Receipt :

of filled up application

Application Number :

Name of the Estate :

1. Name of the Student :

2. Class Studying :

3. Category :

4. Amount of Scholarship Awarded :

5. Father / Guardian Annual income :

6. Name of the Caste & Religion :

Affix passport
size
photograph
attested by the
Principal with
seal

1. Name of the Student (In Capital

Letters as given in Mark Sheet) :

2. Date of Birth & Age :

3. Nationality & Adhaar No. :

4. Religion :

5. Caste :

6. Residential Address with Phone .No. :

a. Present Address
 b. Permanent Address :

7. Are you physically challenged? : Yes / No

8. Father /Guardian Name :

9. Occupation and Annual Income :

10. Office Address with Phone No. :

11. Class in which studying at present :

12. Name and Address of the School /

College / Institution :

13. a) Duration of the Course :

b) Whether Regular / Part Time :

14. Whether the Applicant has passed :

last examination ? and the percentage
of the Marks obtained

15. Whether the Applicant is getting :

any stipend / Scholarship ? and if
So, the source and amount

16. Scholarship amount required (Tuition fees,

Exam fees, Hostel fees etc.)

17. Have you applied towards scholarship :

previously in this office ? if so, the
amount received / year and the name
of the Estate furnish the details

18. Bank Details:- First page of the bank pass book Xerox copy should be enclosed
a) Name of the bank :
b) Branch & Place :
c) Account No. :
d) IFSC code :

19. Mobile No. :

20. Email :
DECLARATION

I declare that the above said information are true to the best of my knowledge and if found
to be false I agree to refund the scholarship award amount.

SIGNATURE OF THE PARENT / SIGNATURE OF THE STUDENT

GUARDIAN
PLACE:
DATE :
 CERTIFICATE FROM THE HEAD OF THE INSTITUTION / SCHOOL/COLLEGE

1. It is hereby certified that ________________________________________________

Son of / Daughter of __________________________________is a bonafide

Student of_______________________________________________________Class /

Courses on Our College.

2. The particulars given by the student are correct as per the record of the college /
Institution.

3. The student’s character is satisfactory / not satisfactory.

4. The student has received / not received scholarship from any other institution.

5. The student is / not physically handicapped.

6. The school / college / institution is government / government aided /

private ( state clearly).

7. The college / institution is affiliated to________________________________ University

8. If the student leaves studies, the fact will be intimated to the office of Administrator General and
Official Trustee of Tamil Nadu, High Court Campus, Chennai-600 104.
Ph.No. 044-2534 2278.

PLACE:
DATE :

SIGNATURE OF PRINCIPAL/
HEAD OF THE INSTITUTION
WITH SEAL
 GENERAL INSTRUCTIONS TO THE CANDIDATES

Scholarship is awarded for any Under Graduate, Medical Course and Technical Education
Students only.

ELIGIBILITY / CONDITIONS TO GET SCHOLARSHIP :

1. The student should have passed previous year examination.

2. The student should have studied in a recognized institution.

3. Student should not be in receipt of scholarship from government or private institutions.

4. Only one applicant from a family is eligible for scholarship.

5. The annual income of the parent / guardian should be within the ceiling of Rs.2,50,000/- in
consonance with the norms of the government.

ENCLOSURE TO BE ATTACHED WITH THE APPLICATION:

1. Community Certificate should have been obtained from the competent Revenue Official not
below the rank of Deputy Tahsildar.

2. The Income Certificate issued by Tahsildar should have been obtained after 31.03.2022.

3. The physically challenged applicant should enclose disability certificate.

4. Fees details from the Institution should be enclosed.

5. Self addressed envelop with stamp for Rs.10/- affixed has to be enclosed.

6. Copy of the Adhaar Card should be enclosed.

7. Copy of Bank pass book.

INSTRUCTIONS

1. The receipt of application with the necessary enclosures should reach this office on or before
27.10.2022.
2. The above said certificate should be SELF attested.

3. The application without proper enclosures, proper particulars unfilled application and application
received after stipulated last date will be summarily rejected.

4. The applicant studying in the evening college should attach unemployed certificate issued by the
Principal / Head of the institution. Correspondence courses not eligible.

5. Those who are First Graduate in their family are not eligible to apply for this scholarship. Since
they get fees exemption as per government order.

Administrator General and

Official Trustee of Tamil Nadu