Paste one passport

Size photograph of

Child duly attested

 

APPLICATION FORM-SPECIAL SCHOLARSHIP SCHEME FOR 
WARDS OF NAVAL PERSONNEL WHO DIE IN HARNESS

PART-I

1. Personnel Particulars of Father.

(a) Personal Number ...................................
(b) Rank ...................................
(c) Name ...................................
(d) Ship/Establishment last served ............................
(e) Date of death ...................................
(f) Name of present Guardian ............................
(g) Relationship with the Child............................
(h) Address of Guardian: ............................ Village : ...................................
Post Office : ............................
Tehsil : ...................................
Distt : ...................................
State ...................... PIN : ............................ (j) Nearest Branch of Syndicate Bank ......................................................................................
(k) Pension Payment Order No. (attach copy duly attested)
(l) Details of all children in order of their age:
S.No. Name  Relationship  Date of Birth
(i)      
(ii)      
(iii)      
(iv)      

(m) Rate of family Pension and children allowance per month ...................................................

Part II

2. Particulars of the Child

(a) Name .............................................
(b) Sex Male/Female ...................................
(c) Relationship .............................................
(d) Date of Birth .............................................
(e) Class passed & % age of marks ............................
(attach attested copy of marks sheet)
(f) Present course of study ...................................
(attach bonafide studentship certificate from the institution)
(g) Year of Admission ...................................
(h) Duration of the course ...................................
(j) Name of the institution ...................................
(k) If college, Board/University to which affiliated ............................
(l) Details of Expenditure per year (attach original receipt) : (i) Tuition fees ............................
(ii) Books/Stationery ............................
(iii) School Bus Fees ............................
(iv) Other expenses ............................
Total Rs ............................ (m) If Hosteller, Amount of fees paid (attach original receipt)
(n) Whether the child is in receipt of any other scholarship/stipend or any other
financial assistance from any other source if, yes the amount received Rs..............................................

Certified that I have not applied/received any other education scholarship from Centre/State Govt., KSB/RSB or any other source for the said child. Also certify that above particulars are correct and any false statement made by me will render me ineligible for scholarship.

 

Date:

 Signature of the Guardian...............................

Name..............................................................

Relationship with child....................................

Part III

3. School/College Attestation

Certified that the facts given in Part II above are correct as per record.

 

Stamp with date Signature of the Head of the School/Institution.............

DECLERATION -CUM PRE-RECEIPT FOR SPECIAL
SCHOLARSHIP SCHEME

1.     Received from the Directorate of Ex-Servicemen Affairs, Integrated Headquarters of Ministry of Defence (Navy), New Delhi, a sum of Rs…………… (Rupees………………………………………….only) being the amount of special scholarship awarded to my child for the academic year …………. as detailed below:-

Name of the Child Course of Study Institution
     

 2.     I do solemnly declare that my above child is not in receipt/claimed of any scholarship for the course of study mentioned above from other source(s).

3.     I certify that the above information is correct and nothing has been concealed therefrom.

4.    I undertake to refund the amount of scholarship to the Directorate of ex-Servicemen Affairs, naval Headquarters, New Delhi, if my above child is found to be getting any other scholarship or granted other scholarship for the aforesaid course of study at a subsequent date.

Station:

Date:

 

(To be signed over one Rupee revenue stamp)

Name Smt _______________________
W/o ate Shri ________________
Rank__________ No__________

COUNTERSIGNED

 

(CO/EXO/GAZETTED OFFICER/Secy DSSA&B
with Name Designation and seal) Office Stamp

Place:________________

Date:______________________

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