THE KARNATAKA STATE WAKF FOUNDATION FOR WOMEN DEVELOPMENT

# 215, 2nd Floor, Vikasa Soudha, Dr. Ambedkar Veedhi, Bangalore -560001
[For Muslim Women Only]

APPLICATION FORM FOR SCHOLARSHIP FOR STUDENTS OF PROFESSIONAL COURSES

(MBBS, BDS, BE, BUMS,BAMS,BHMS,MBA,MCA,BCA,BBM,B.Sc(Agri), B.Sc(Hort), B.VSc.)
-: Application should be filled in capital letters only: -

LAST DATE TO SUBMIT THE FILLED APPLICATION IS 16th NOVEMBER 2009

One more attested

p. p. size photo of Affix passport size
the student similar photograph of the
to the one affixed on student with
the applicant is to Signature thereon
be pinned
Here

01. Name in full

02. Date of Birth and Place

03. Nationality and Religion

04. Postal address with PIN Code.
(a) Present: (b) Permanent:
.................................................................... .....................................................................................
.................................................................... .....................................................................................
.................................................................... .....................................................................................
...................................Pincode: .................. …………....................................Pincode: ..................

05. Marital Status Married: ( ) Single : ( )

06. (a) Name of Father / Mother /Guardian

(b) Nationality and Religion

(c) Occupation

(d) Address
(a) Present: (b) Permanent:
.................................................................... .....................................................................................
.................................................................... .....................................................................................
.................................................................... .....................................................................................
...................................Pincode: .................. …………....................................Pincode: ..................

Total annual income from all sources of

07. Rs.
Parents / Guardian.

Continued...02
 Particulars of all examinations passed commencing with the Matriculation or Equivalent
08.
Examinations.
Class /
Name of University / Year of division
Sl. examination Board passing
Roll Subjects
with %
No. number Taken
and marks
(Rank if any)
0 1 2 3 4 5 6

.........................................................................................
(a) Name & address of the institution
09. where admission is secured for the .........................................................................................
current academic year.
.........................................................................................

(b) Is admission through C.E.T. ? Yes: ( ) No: ( )

(c) If Yes, Ranking Number with
other details (enclose documents) .........................................................................................
..........................................................................................
If No, how the admission is
secured. ..........................................................................................
(d) Date of admission and
Date: Adm. No.
Admission Number.

(f) Course and Subjects taken. .........................................................................................

.........................................................................................
(g) Number of years required for
completion of the course.
(from the date of admission)
(h) Whether Repeater or Fresher

If you have been sanctioned Scholarship earlier by Karnataka State Wakf Foundation for Women
10.
Development? If so, please specify.
(a) Order Number and
Date of sanction.
(b) Amount sanctioned. Rs.
(c) During which course / class
sanctioned.
If the applicant is in receipt of any
.........................................................................................
other scholarship or financial
assistance from Central Govt./State .........................................................................................
11. Govt./ University or any other
.........................................................................................
Institution, particulars should be
given including monthly rate and the .........................................................................................
date of sanction.
Amount of financial assistance now
12. Rs.
required.
Continued...03
 13. List of documents to be attached (enclosed) YES ( ) NO ( )
(a) Fee Receipt
(b) II PUC Marks Card
(c) CET Admission order
(d) College Admission order
(e) Income Certificate from the Tahsildar
(f) Previous years Marks Cards

Note: All copies should be attested by a Gazetted Officer / Head of the Institution.

I hereby declare that the statements made by me in this application form are true to the best of my
knowledge and belief.
Place :..............................
Date :.............................. ………………………………
Signature of the applicant.

DECLARATION BY PARENTS / GUARDIAN

I, ....................................................................... hereby declare that the facts mentioned above are true to the best
of my knowledge and in case any of the statements made above are found to be false, I hereby undertake to
refund the scholarship amount to Karnataka State Wakf Foundation for Women Development, Minority
Welfare Department, Bangalore.
Place :..............................
Date :.............................. ........................................................
Signature of the Parent / Guardian

CERTIFICATE BY THE HEAD OF THE INSTITUTION

1. This is to certify that Kum:........................................................................................ daughter of

Sri./Smt.................................................……….... is studying in ..................... Class / Semester/ Year and that
she has secured admission through .........................…………………………….………………
2. Kum:.......................................................................... is not a repeater in class ..................... in which
she is presently studying.
3. I hereby recommend to consider her case for sanction of scholarship scheme of Karnataka State
Wakf Foundation For Women Development, for .…………............ Class /Semester/Year as the income of the
family is Rs..................... per year (Rupees.....................................................................................................)
4. The Student is required to pay an annual (admission & tuition) fee of Rs…………………..

Place :..............................
Date :.............................. ..............................................................................
Signature of the Head of the Institution with Seal

N O T E: Scholarship is admissible only for the applicants whose family income is

NOT MORE than Rs.2.50 lakhs per annum.