Application Form

INCOME LINKED TUITION FEE WAIVER SCHEME

Academic Year 2015-16
INSTRUCTIONS
1.
2.
3

Please go through the eligibility criteria

Bank Account must be in the name of the student applying for scholarship
Application duly filled to be submitted to Hansa Gohel, Admin Office between 3 pm to 5 pm

Last date for submission: 16 March 2016, 5 p.m.

PERSONAL DETAILS
Name of Applicant
Faculty

Program

Code No

Email ID

Presently registered semester

Mobile No

GPA of previous semester /

last qualifying exam
FAMILY DETAILS
Name of Parent / Guardian
Relationship with Candidate
Address
City

State

No of earning members in
family
Occupation/s

Pin Code
Annual Income
(2014-15)

BANK DETAILS
Name of Account Holder
Name of Bank &
Branch Address
Account Type
IFSC / NEFT Code
Account Number
DECLARATION
1. I hereby certify that I am not a recipient of any Scholarship - CEPT University/ GOG / GOI / NGO or any
other source
2. I am submitting herewith the required documents in support of my application
a) Income Tax Return (Financial Year 2014-15 i.e. Assessment Year 2015-16)
b) Bank statement of FY 2014-15 (salary or business account)
c) Income declaration by the self-employed parents/guardians, stating definite income from all sources by

way of an affidavit on non-judicial stamp paper

d) Photocopy of CEPT Fee Receipts (student copy)
e) Result Grade Report of last semester (Monsoon Semester 2015-16)
f) Bank details (copy of pass book or cancelled cheque)

3. I certify that the statements furnished herein are true to the best of my knowledge and grant my permission for
this information to be shared with scholarship selection committee.
Signature of Applicant

Date of Application

RECOMMENDATION OF DEAN
I hereby approve of the above application and recommend this nomination for the above financial aid.
Signature of Dean

Date of Approval

FOR OFFICE USE ONLY

Received by

Date of Receipt