bazm-e-niswan2011application - SECAB

Bazm-E-Niswan Charitable Trust (R)No.37, Muniswamy Road, Tasker Town, Bangalore - 560051.Phone: 080-2286 0023 / 2286 5231 Email : bazmeniswan@hotmail.comWebsite: www.bazm-e-niswan.orgPROFESSIONAL EDUCATION SCHOLARSHIPS - 2011For students seeking Admission to 1 st year in Professional CoursesBE, MBBS, BDS, B.Arch, BUMS, BAMS & BHMS On merit basis through CET 2011 only.Eligibility Criteria1. Students who have passed 2 nd PUC science or 12 th std science and CET 2011 exam securing(a) Medical Rank within 4000 (b) ISM Rank within 20,000 (c) Engineering rank within 30,000.2. The annual income of parents’/guardian should not be more than Rs.1 Lakh.3. The student should be eligible & willing to receive ZAKAT funds.4. Separate funds have been reserved for poor & deserving “SYED” Students.APPLICATION FORMNo.For Official Use OnlyCategory Date of Receiving Date of InterviewMED / ISMH / ENGGStatusSANCTIONED / REJECTED / PENDINGAmount SanctionedPlease paste here(do not staple )recent colorPassport sizePhotographSignature of PresidentSTUDENT DETAILS(To be filled up by the Student only in his/her own handwriting)Student Name (in CAPITALS)Gender Male ( ) Female ( ) Date of Birth :CET 2011 Hall Ticket No. Category :CET 2011 Ranking Medical : ISM : ENGG :CET 2011 Counseling Date Medical : ISM : ENGG :CET 2011 Counseling PlaceBangalore ( ) Hubli ( ) Gulbarga ( ) Mangalore ( ) Shimoga ( )Belgaum ( ) Chitradurga ( )PES 2011 P a g e | 1

DETAILS OF PARENTS’ / GUARDIAN & ANNUAL INCOMEFather’s NameFather’s Occupation Annual Income :Guardian’s Name(In case of Orphans)Guardian’s Occupation Annual Income :Any financial burden due to : Loans ( ) Medical Expense ( ) Marriage Expense ( ) Others ( )DETAILS OF FAMILY MEMBERS – BROTHERS & SISTERSKindly enter details of your family members. Use “Y” to denote Younger and “E” to denote ElderNo. Relationship Name Age Class Studying / ProfessionMarried(Yes/No)Example Brother (Y) Salman Khan 15 10 th Std No123456ACADEMIC & OTHER DETAILSExamPassedBoard(State /ICSE/CBSE)Institution Name & Address(Please write the address clearly with PINCODE)Year ofPassing% ofMarksSSLC /10 th Std2 nd PUC/ 12 th StdReligion : Caste : Place of Birth :Medium of Study till 10 th Std : Kannada ( ) English ( ) Urdu ( )Any achievements, prizes won at school / college ?PES 2011 P a g e | 2

CONTACT DETAILSFull PostalAddress( in CAPITALletters)PINCODE : Taluk : District :Phone No. (with STD Code) : Mobile No :Email ID :All attachments listed below are compulsory. Please put a tick () in the brackets to indicate the documentsyou have attached. Kindly do not attach any original documents.Xerox copy of SSLC / 10 th Marks Card : ( )Xerox copy of 2 nd PUC / 12 th Marks Card : ( )Xerox copy of CET 2011 Hall Ticket : ( )Xerox copy of CET 2011 Marks Card # : ( )Xerox copy of Address proof document * : ( )Xerox copy of Study Certificate : ( )Xerox copy of Caste & Income Certificate : ( )Note : # Internet Printout of CET results. * Ration Card or Electricity Bill or Water Bill or Identity Card.DECLARATION BY THE STUDENT AND PARENT/GUARDIANPlease paste here(do not staple )recent colorPassport sizePhotograph I hereby agree that all details furnished by me in this form are TRUE. I have not modified /manipulated any details. In case the particulars furnished are found to be incorrect, the organizationcan initiate suitable legal action against me.I shall report to the organization as and when decided by the organization and update about mystudies and career. I assure that I shall pursue my studies very seriously and become an asset for thecommunity and country._________________________________Date : __________________ Signature of the StudentPlace: ___________________________________________________Signature of the Parent/GuardianWhere to submit the filled in application form ?Filled in application forms must be submitted in person or sent through post or courier on orbefore 10 th June 2011 to the below address only.Bazm-E-Niswan Charitable Trust (R)No.37, Muniswamy Road, Tasker Town, Bangalore - 560051. Phone: 080-2286 0023 / 2286 5231PES 2011 P a g e | 3