APPLICATION FORM FOR TATA STEEL MILLENNIUM SCHOLARSHIPS

2017-18

Part - 'A'
Affix
Reference Number 201802600194 Passport
Size
Full Name RAKESH ROUT Gender MALE Photograph
&
Date of Birth 14-MAY-1995 Caste GENERAL Candidate
to Sign
across the
(in case of SC/ST, please attach documentary evidence from Court)
Photograph
Educationl Qualification
Examination Year of Total Marks % Marks
Srl.No School/College Board/University Division
Passed passing marks Obtained (Obtained)
JAMSHEDPUR PUBLIC
1 MATRICULATION C.B.S.E. 2011 50 43 8.60 1
SCHOOL
JAMSHEDPUR PUBLIC
2 HSE C.B.S.E 2013 500 434 86.80 1
SCHOOL
JAMSHEDPUR KOLHAN
3 B.COM(H) 2016 800 572 71.50 1
WORKER'S COLLEGE UNIVERSITY
*Application forms with error in calculation of percentage of marks will be liable for rejection

Name, University of the College / Institution / where admitted.

Name of INTERNATIONAL SCHOOL OF BUSINESS &
University AICTE
College/Institute MEDIA
Address of College / S. NO. 44/1, 44 1/ 2, NANDE VILLAGE PASHAN
State MAHARASHTRA
Institution SUS ROAD, PUNE 412 115
PIN 412115
Details of
Course to
Date of Admission 19-JUN-2017 P.G.D.M.
which
admitted
Duration of
the
Discipline MARKETING AND FINANCE 2 YEAR
Course(In
years)
Total Tuition
Nos. of Semesters 6 Fee in 890000
Rupees
College Registration ID College
170593 PRIVATE
No. / Roll No. Type
Any member of the family is currently
benefiting from any Scholarship awarded NO
by Tata Steel
I am availing any aid/scholarship from any
NO
other College / Institution
I am applying scholarship for CATEGORY B
Got admission in Post Graduation
Candidates already availing scholarship are not eligible to apply.
i I confirm that the information I have furnished is correct and true.
I confirm that in case any information provided above is found incorrect the company besides cancelling the scholarship may also
ii
take legal action against me.
I am not getting any aid/scholarship from other college/institution. In case I start getting any aid/scholarship from any college/
iii
institution after getting Millennium Scholarship then I will inform the Committee to discontinue the Millennium Scholarship.
iv I confirm that the decision of the Tata Steel Millennium Scholarship Committee will be final and binding on me in all respect

Date:................. Name & Full Signature of the Applicant

Place:.................

Part - 'B'
I, PRASANA KR ROUT Father/Mother/Husband of RAKESH ROUT Confirm that the statements made in Part - 'A' by my
Son/Daughter/Spouse is correct.

Personal No. 306030 Grade S 14

Designation SENIOR OPERATOR Department ST MILL OPERATIONS

Relation Son

Status Employee

(Enclose photocopy of the Service Certificate)

----------------------------------------------------------------------------------------------------------------------------------------------
TelePhone(Office with TelePhone(Residence
STD code) with STD code)

RAKESH.ROUT@ISBM.AC.IN
Mobile 07631043608 Email

Postal Address for communication

Address for Q.NO.-TJ2/19,KADANI ROAD,OLD

City / Village / District EAST SINGHBHUM
Communication BARIDIH,JAMSHEDPUR

State / Union Territory JHARKHAND Pin 831017

----------------------------------------------------------------------------------------------------------------------------------------------
Bank details of Student

Name of the Bank STATE BANK OF INDIA City JAMSHEDPUR

Branch BARIDIH Account No. 35160074718

Ifsc Code SBIN0009009

(Name of Father / Mother /Husband)

(Signature)

Part - 'C'
We hereby certify the following:

Name of the Candidate RAKESH ROUT

Son/Daughter/Spouse of PRASANA KR ROUT

Course Name P.G.D.M.

Date of Admission 19-JUN-2017

Duration Of Course (in years) 2 YEAR

Date of Commencement of
01-APR-2019
Sesssion

Course is FULL TIME

Registration No / Roll No. 170593

*------------------------------------------------------------------------------------------------------------------ --------------------*
 Institute Details
(Please attached recognition / affiliation certificate of the institute

Name INTERNATIONAL SCHOOL OF BUSINESS & MEDIA

Postal Address S. NO. 44/1, 44 1/ 2, NANDE VILLAGE PASHAN SUS ROAD, PUNE 412 115

State MAHARASHTRA

PIN 412115

Phone 07757029572

Fax 02066754678

Email

Website HTTP://WWW.ISBM.AC.IN/

University affiliated to: AICTE

(Head of the Institution)

Signature with Seal
 Part - 'D'
(Declaration by employee / ex-employee)

In case of employee's on roll of the Company

The terms and conditions of the said scholarship are acceptable to me. The information provided in the application is correct to the
best of my knowledge. It is certified that the employee is presently working in the department as per details given in part 'B' are correct.

Date:................. Name & Full signature of the employee

_____________________________________________________________________________________________________________________________
Verify by

Head of the Department with seal.

_____________________________________________________________________________________________________________________________
In case of Retired/ESS/MSS/EFBS/FBS employee

Date:................. Name & Full signature of the Ex-employee

_____________________________________________________________________________________________________________________________
Verify by

Head of the Employment Bureau / HRM

_____________________________________________________________________________________________________________________________

List of documents to be submitted along with this application:

Self Attested Xerox copy of the original mark sheet of the last qualifying Examination
One passport size photograph to be affixed in part A of the form.
Photocopy of reciept of Tution fee
Photocopy of Service certificate in case of ESS/Retired/MSS/EFBS/FBS employee issued by the company.
Photocopy of cancelled cheque mentioning the name of the candidate.
In case of SC/ST, please submit documentary evidence from Court with hard copy
Please attached recognition / affiliation certificate of the institute.

Percentage of Marks would be calculated on the basis of Mark obtained in the examination divided by Total Marks
in the Examination in their last qualifying examination.
In case of Grade system of assessment, please get the mark sheet converted into percentage of marks duly
certified by School/College authorities.