Page 1 of 4 Annexure A BHARTI SCHOLARSHIP FORM (Applicant ...

Annexure A(To be filled up by Bharti office only)BHARTI SCHOLARSHIP FORMApplication No.-----------Financial Year(month/year)--------------Date------------(Applicant must fill in all the fields neatly hand written or typed in capital letters. If anyfield is not applicable to the applicant, please write not applicable)A. PERSONAL DETAILS1. First Name ……………………………………………2. Middle Name ……………………………………………3. Last Name …………………………………………… Affix photograph4. Nationality ……………………………………………5. Date of Birth ……………………………………………6. Sex Male Female7. Disability(if any pleasemention in detail) …………………………………………………………………8. Father’s Name .………………………………………………………………..9. Occupation ………...………………………………………………………10. Mother’s Name …………………………………………………………………11. Occupation …………………………………………………………………12. Total AnnualIncome of thefamily…………………………………………………………………13. Address forcorrespondence(apart from Instituteaddress)…………….……………………………………………………14. Telephone no. …………….……………………………………………………15. Email ID …………….……………………………………………………B. ACADEMIC DETAILS1. Course Name ……………………..……………………………………………2. Duration of Course(no. of years) ……………………..……………………………………………3. Rank in CommonAdmission Test (CAT) …………………….……………………………………………4. Annual estimate of fund required for the course per year (in Rs.) ……………….a. Tuition fees …………………..……………………………………………..b. Books ……………….…………………………………………………1Page 1 of 4

c. Institute/College Hostel Charges ……………………………………………..d. Any Other(please mention in detail) ………………………………………………….C. EDUCATIONAL QUALIFICATIONSName ofexaminationStandard XIIYear Board/University/Institution Division/Class/Grade %obtainedGraduation and above: (If result of final year are not received, mention upto latest result)Degree Year Subject Institute/University Class/Grade %obtainedD. QUALITATIVE ACHIEVEMENT1. Please mention any academic distinction, grants, scholarships and prizes receivedby you.2. Please share your achievements so far in any field (not exceeding 200 words.)3. Attach a personal statement (not exceeding 200 words) sharing your dreams,achievements, aspirations and life-goal.2Page 2 of 4

The candidate is required to give two references of reputed persons other than his/herrelatives. The Foundation will be at liberty to refer to them regarding the candidate’seligibility for the scholarship.(1) (2)Full Name ……………………………… .……………………………….Occupation ……………………………… ..……………………………….Full address ……………………………… …………………………………and contact no. ………………………………………………………………………………………………………………………………………………………………………………………………………Relationship withCandidate ………………………………. …………………………………I, hereby declare that the above information furnished by me is true and correct in allrespect.Signature of the ApplicantFull NamePlace and Date………………………………………………...…………….………………………………………………………………………………………………………………………………………………Authorization by Head of the InstituteI solemnly declare that the Scholarship Committee of the Institute has taken duediligence and the above information (especially point no. A.7, A.12, B.3 and C) furnishedby the applicant is true and correct in all respect to the best of my knowledge. I,therefore, recommend his/her candidature for the Bharti Scholarship Scheme.SignatureNameDesignationDate……………………………………………………………………………………………………………………………………………………………………………………………………………………Seal of the Institute3Page 3 of 4

General Terms and Conditions1. It is essential that the candidate fills in all the information in the application formcorrectly and truthfully. If it is found that student had made false statement in theapplication form, the foundation will have full discretion to stop the scholarship.2. On receipt of the intimation of grant of scholarship the candidate is to inform his/herbank details to Bharti Foundation to enable easy remittance of scholarship amount.3. A confirmation letter from the scholar on receiving the cheque should be sent toBharti Foundation within 10 days, as a receipt of the cheque.4. A change of stream after allotment of the scholarship will lead to disqualification fromthe scheme.5. A scholar who has dropped a semester shall be disqualified as a scholar, exceptwhen partner Institute has canceled the semester due to any reason. However, ascholar who has dropped the semester on medical ground shall be eligible for thescholarship.6. For renewal of scholarship, the Bharti scholar will send a request letter within 15days after the announcement of the result, giving details of his/her academicachievements in the last academic year and letter of recommendation from the headof the Institute (as per the formats), and it will be renewed based on the renewalcriteria.4Page 4 of 4