Application Form

Tribal Youth Initiative

SETU Scholarship
Registration Form for Medical and Engineering entrance
exam

1. Name of the applicant (In BLOCK letters)

:
______________________________________________________
Affix the passport
2.Fathers Name size photo
:_________________________________________

3.Date of Birth : _______________________

4.Age : ______________________

5. Gender : _______________________

6. Contact Details

Recent Address Permanent Address

Name: Name:

Address: Address:

City: City:

State State

Pin code: Pin code:

Email : Email :

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Telephone No: Telephone No:

Mobile No: Mobile No:

7. Applied for : Medical/Engineering --------------------------------------------

8. 12th Higher Secondary - Passed or Appearing in the exam

.

9. Education Qualification

Qualificati Universit Subject From To Marks

on y/ Board (Month/Ye (Month/Ye obtained
ar) ar) (CGPA/Perc
entage)

10th
( Seconda
ry)

12th ( High
Secondary
)

Other
Qualificati
on

10. Extra curriculum activities and achievements

Sl.No Details

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11. Language

(5. Very Good, 4.Good, 3. Medium, 2. Poor, 1. Very

Poor)

Language Read Write Speak

12. Share about your family background and yearly income-

13. Did you have caste certificate- Yes/No -----------------------------------

14. Note- A copy of all the original documents and certificate will be
needed at the time of final selection.

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Declaration: I hereby declare that all the information given is true to
the best of by Knowledge

Date:

Place:
Signature of the Applicant