INDIAN INSTITUTE OF MANAGEMENT BANGALORE

MIRAE ASSET FOUNDATION SCHOLARSHIP (for PGP 2019-21 Batch)

APPLICATION FORM
1. Background Information:

CAT Registration No. 8067696

Roll number (IIMB) 1911425
Name of the Applicant (Full Name) Anand R Moon
Male Female
Gender (Please tick)

Date of Birth (DD/MM/YYYY) 28/11/1995
Marital Status Unmarried
General NC-OBC SC ST DA
Category (Please tick)

PAN No. CSGPM3006C
Passport Number

2. Contact Details:

Add line 1 : c/o Smita Onkar, Bhimwadi, Thool Layout

Add line 2 Sindi-Meghe, Wardha
Add line 3:
Permanent Address Town /City : Wardha
State : Maharashtra
Pin code : 442001
Contact Number: 9511658902

Add line 1 :
Add line 2
Add line 3:
Current Address Town /City :
State :
Pin code :
Contact Number

3. Academic Background:

Academic Name of the Board Name Degree Place of Year of % of Marks

level college/institute Name study completion obtained

SSC

PUC/HSC/
12th

Bachelors

Masters
(if any)

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4. Work Experience:

(a) Do you have any work experience after completion of Bachelor’s Degree? Yes/No
If yes, kindly provide the following details:
No. of Gross annual
Name of the Organisation Designation Place of work months salary
worked (in Rupees)

Total Number of months worked

(b) Are you on study leave/ sabbatical from your current employer? Yes/No
(c) Have you travelled abroad in the past three years? Yes/No
If yes, provide the following details:
Period (from- to)
Country travelled to Purpose of the travel Sponsor of the trip
(mm/yy) to (mm/yy)

5. Household Information: Provide the details of all the family members. Also provide details of the members such as
married siblings not staying with the family but contributing.

Is he/she Is he/she
Relation Gross
Name of the contributing Name of the income tax
with the Occupation Designation annual
person to the house organisation assesse
applicant salary
(Y/N) (Y/N)

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6. Property/Assets: Please provide the details related to house, land and other assets owned by you and your family:

House information:
Own house Rented house
Home (Please tick)
Location
Size /Type
Monthly rental income (if owned and given for rent)
Monthly rent paid (if not owned)

Land information:
Land /site :size (sq ft)
Location
Agricultural land Others
Land Type (Please tick)
Monthly rental income (if owned and given for rent)
Monthly rent paid (if not owned)

Other property /assets: Please tick ‘yes’ or ‘no’ for corresponding items and provide the other details:
Item Yes No Type Value (in Rs.) Age (in years)
Model Name Year of purchase
TV
Home Theatre system
Computer and
ancillaries
Digital/ video camera(s)
Washing Machine
AC
Cooking Range
Two Wheeler(s)
Four Wheeler(s)
Other (Specify)

7. Savings: Indicate amount for existing stock of all household savings:

Approximate yearly interest

Fixed and other saving / investments Applicant’s Family’s
earnings
PF/PPF
Term Deposits
Saving Certificates
Bonds
Mutual Funds
Equity Holdings
Bank Current Savings
Others
Total

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8. Loans: Provide the details pertaining to educational loans taken for self and other personal loans:

Educational Loans:
Whether applied for an educational loan Yes No
(Please tick)

If not applied for educational loan, provide

the reasons

If yes, give the status of loan (Please tick) Approved Rejected Awaiting approval
and also provide proof as per status
Amount of loan
Terms and conditions of repayment
Security / Collateral used

If loan applied by you is rejected, provide a

letter from the bank indicating the same
(state reason for rejection)

Have you taken any other loans (housing, car, sibling’s education etc.) for household? Yes /No
If yes, provide the details below:
Source Loan -1 Loan -2 Loan-3
Amount
Purpose
Against collateral
Repayment terms

9. Any another relevant information that you would like to provide?

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 REQUIRED SUPPORTING DOCUMENTS
1. Attach copies of pay slips/latest income tax returns of the applicant (if relevant see item -4(b) and 4(c)).
2. Attach copies of pay slips/latest income tax returns for all earning members of household (if relevant-see item
5).
Case (i): In case your family members do not file tax returns due to low income please provide a copy
of the pass book for the bank that your family uses. Please provide transactions for the last one year.

Case (ii): In case your family members have not filed tax returns for this year as yet, please provide
the IT returns for last year and Form 16/16A etc. showing all income for the current year.

3. Proof of property, house, land and other assets owned by you and your family members (if relevant see item
(6)).
4. Proof of savings (fixed and current) certifying information-see item (7)).
5. Attach evidence for educational loan status (approved, rejected, and pending approval-see item (8)). Also
provide the proof for any other loans taken by you or your family member

PLEASE PRINT A COPY OF THE FILLED IN APPLICATION AND SIGN THE DECLARATION BELOW:

I hereby declare that all the information given in this form is true to the best of my knowledge. I authorize the
institute to verify any of this information. I understand that if the information is found to be false, I will forfeit all
claims to financial aid and that the institute may take disciplinary action against me.

Name: Signature:

Date: Location:

*NOTE REGARDING SUBMISSION OF APPLICATION

Please note that you are required to send a scanned of application to financialaid@iimb.ac.in and also submit the
hard copy of the application to admissions office on or before September 09, 2019 (5.00 p.m.)

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