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CENTRAL SECTOR SCHOLARSHIP 2011-12
Affix recent
passport size
Photo.
To be signed
by the head of
present Institution
Registration ID 010035262409
1) Name Of The Candidate SALMANUL FARZY
2) Date of Birth 30/05/1994
3) Sex Male
4) (a)Category OBC
(b)Physically Challenged No
5) Details of Father/Husband/Guardian
a)Name NIZAM ALI
b) Permanent Address NAZEEMA MANZIL,PAZHAYA PATHA,KAMBRATHUCHALLA,MUTHALAMADA,Kerala,Palakkad,678507
6) Details of Communication
a) Correspondence Address NAZEEMA MANZIL,PAZHAYA PATHA,KAMBRATHU
CHALLA,MUTHALAMADA,Kerala,Palakkad,678507
b)TelePhone Number with STD Code 04923-201606
c)Mobile No 9809742694
d)Email ID [email protected]
7) Nationality Indian
8) Annual Income 239040
9) Particulars of School/Institution last attended Class XIIa) Name Of Institution GOVT HSS, KODUVAYUR, PALAKKAD
10) Details of Class XII Examination Passed by the Candidate
a) Name Of Student SALMANUL FARZY. N
b) Plus two Register Number 7201918
c) Name Of Examination Passed HSC,Physics, Chemistry, Biology,Mathematics
d) Year of Passing 2010-11
e) Percentage of marks obtained in aggregate 86.67%
11) Receiving any Other Scholarship NO
12) Details of Present Course and Institutions
ii) Name of the Course Joined PROF-UG,Computer Science and Engineering
iii) Name of the Institution Engineering College, Idukki13) Details of Bank Account
i) Account Number 67119898978
ii)Name of the Bank STATE BANK OF TRAVANCORE
iii)Branch Code and Address 180,P.B.NO.1, Adithya Towers, Near Althara,Main Road,
Koduvayur
IT Services:National Informatics Center(NIC),Kerala Page 1/2 Printed On: 10/11/2011 16:31
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CENTRAL SECTOR SCHOLARSHIP 2011-12
Registration ID 010035262409
Full Name SALMANUL FARZY
14) Documents enclosed with the application
(i) One copy of passport size photograph with signature pasted on the registration form.
(ii) Attested certificate of matriculation examination.
(iii) Proof of permanent residence/Nativity Certificate
(iv) Attested copy of first page of bank pass book in the name of the student., showing the Account Number,Name,Code.
(v) Annexure-II (Entitlement Card) [to be filled by the Principal].
(vi) Annexure-III (Income Affidavit): Parental income of the student as on March 2011 should be shown.
(vii) Non Creamy-Layer Certificate, Community Certificate, Disability Certificate in case of Physically Handicapped
applicants etc. should be produced in original wherever applicable.
(viii) Copy of the +2/ VHSC Mark list attested by a Gazetted Officer.
15) Declaration by the candidate
(i) Certified that the statement made by me in this form is correct.
(ii) I declare that in case I am selected for a scholarship. I shall devote my full time to the course of study.
(iii) I Hereby declare that I am not availing any other Scholarship.
Place:
Date: Signature of Candidate
16) Remarks by Verifying Officer
Verified online the details given by the candidate with supporting documents and found
Correct/ Incorrect (Specify)
Place: Signature of Verifying Officer
Date: name:
Designation:
17) Certificate by the Head of the Institution
1) This is to certify that Shri/Smt./Kumari ....SALMANUL FARZY......... S/o,W/o,D/o Shri/Smt..........NIZAM ALI...........
who has passed the Plus Two Examination held in March/April 2011 conducted by ...HIGHER SECONDARY (STATE)....
with Roll No ....7201918.....and has been granted admission in this institution on ....01/09/2011.....for the.....Computer
Science and Engineering .....Course He/She has started attending the First Year class with effect from
……………………………………., 2011
2) It is further certified that the information furnished by the student is correct.
3) The completed Statement of Particulars (Annexure–IV) and the Income Affidavit Form (Annexure–III) are alsoenclosed.
Place: office Seal
Principal
Date: Engineering College
Idukki
IT Services:National Informatics Center(NIC),Kerala Page 2/2 Printed On: 10/11/2011 16:31