APPLICATION FORM

PERSONAL INFORMATION

Candidate’s Name

Father’s/Guardian’sName

Mother’s Name

Telephone No

Mobile No. (Parents mobile no. can be provided):

Email:

DomicileState/UT(State/UTwhichthestudentbelongsto):

DateofBirth(DD/MM/YYYY) Nationality

AnnualFamilyIncome(Rs.) Category: General ST SC OBC

Person with Disability (PwD)? No Locomotor Disability Dislexic Hearing Impairement

VisualImpairment Spastic Autistic

ADDRESS FOR CORRESPONDENCE

City/Town/Village&PO

District State Pincode

Phone Mobile

PERMANENT ADDRESS :

City/Town/Village&PO

Affix a self attested

passport size photograph

District State Pincode

Phone Mobile

AnnualFamilyIncome(Rs.)

DETAILS OF EDUCATIONAL qUALIFICATIONS:

Name of the School Studying in

Board School Affiliated with

School Address

City/Town/Village&PO

State Pincode

School Telephone No.(Including STD code)

School Email-ID

Principal’s Name Principal’s Mobile

Presently Studying in: Class XI Class XII

EXAMINATION PASSED

BOARD YEAR OF PASS OVERALL CGPA/PERCENTAGE

SUBJECT GP/ PERCENTAGE

Class X

Class XI(ForclassXIIstudents only)

Given in CGPA or Percentage?

CGPA Percentage

Maths: Science:

Physics : Chemistry :

Maths:

DETAILS OF OThER EXAMINATIONS /TEST CLEARED

NTSE Maths Olympiad Science Olympiad KVPY NSEJS NBHM Other

DETAILS OF BANk ACCOUNT OF STUDENT

Name of the Bank

Branch address

Bank Account No.

IFSC/RTGS/NEFTCode(11DigitAlphanumericCodeoftheBank)

Preference of city in which you want to attend the contact classes (choose from the list of cities given in the brochure)

1

2

3

Annual Income of parent/guardian of the student : Rs (SpecimenformofdeclarationofannualincomeisgivenatAnnexurewhichistobesignedbytheparent/guardianofthestudentandenclosedalongwiththeapplication.Incaseparent/guardianareemployed,incomecertificatefromtheemployer may also be enclosed)

Documents enclosed with the application(i) One copy of passport size photograph with signature.(ii) Selfattestedcertificatesofeducationalqualificationasfilledupinpara09.(iii) Income declaration - affidavit on non - judicial stamp paper and income certificate from the employer.

Declaration :(i) I hereby declare that the information given above is correct.(ii) I am not availing any other scholarship for this purpose from any other sources.(iii) I shall abide by the terms and conditions for sanction of the merit-cum means based scholarship.(iv) I undertake, that if at any stage, it is found to the satisfaction of the sanctioning authority that the information given

by me is false or if I violate the terms and conditions of the scholarship, the scholarship sanctioned to me, may be cancelled and the entire amount of scholarship will be refunded by me or recovered from me, apart from liability for such penal action as warranted by law.

Date : Signature of the candidatePlace :

FOR OFFICIAL USE ONLY

Sl No. of Application Year Class Gen/SC/ST/OBC

Annexure

DECLARATION OF FAMILY INCOME

I...............................................................................................(Father/Mother/Guardian)of........................................

............................................(Name of Student) who is studying in ..............................................................................

...........herebydeclarethatmyannualincomefromallsourcesisRs./.........................................inword......................

......................................................................................................if at any stage, it is found that the information given

bymeisfalse/nottrue,allbenefitsgiventothestudentundertheschemeof“UDAAN”couldbewithdrawnandlegal

action as deemed fit may be taken against me or my ward.

SignatureDate :(Father/Mother/Guardian) ResidentialAddress

UNDERTAkING BY PARENT

I ......................................................................(Father/Mother/Guardian) of .....................................................have

understood the terms and conditions of the Udaan program and agree to abide by them. I promise to support my

daughter for the duration of the program and will ensure that my daughter sincerely participates in the program.

I also understand that as part of this program my daughter will be required to attend contact classes on the weekend at

a centre appointed to her. I will support her in attending these classes.

I agree to ensure the safety of the tablet and study material given to her and promise to return the same in the event she

discontinues from the program.

Date:

Signature:

Name: