Details Session of Online Application Form for Tenth Scholarship and Fee Reimbursement

(Renewal) - (2023-24)
(For Deposit in Educational Institute)
(After Revising Questionable Data)
Date of Print:- 15/02/2024
Registration details
District Name: KAUSHAMBI
Name of Educational Institute : MADHU VACHASPATI SCHOOL OF MANAGEMENT KOILAHA KAUSHAMBI
Registration Number: 440510402200120
Name of Student: SYED FAZAL HASAN
Changed name of student if:

Name of Father/Husband: SYED ISHTEYAQUL HASAN

Mother's Name: SYED SHAMA PARVEEN
religion: Muslim
Class/Ethnic Group: minority class
Date of Birth: 11/04/2000
gender: MALE
Mobile, Tel No : XXXXXX0016 ,
Email

High School Board ICSE Year of graduating high school 2016

Name and Address of University/Institution JUMNA CHRISTIAN JUNIOR
High School Board Serial No 6144215
from where High School was passed HIGH SCHOOL ALLAHABD

Academic details
1- Name of the Course: MASTER OF BUSINESS ADMINISTRATION
2-Branch of Course: MBA
3-Type of course: Self financed 4- Year and Duration of Class: 2,2
5-Entry is based on Lateral Entry NO 6-Residential / Day Student: day student
7-Date of entry into the first year 8-Date of admission to the
01/07/2022 01/07/2023
of the course: current session of the course:
9-Registration No. in 10-Name of
UP Technical University,
University/Board/Affiliating 220749070093188 University/Board/Affiliating
Lucknow
Agency Agency:
11- Whether admission to
vocational courses is based on NO 12-Course Eligibility: Graduate, B.Sc
class 12 marks/merit:
13-Whether the admission to the
current course is through
NO 14-Entrance Exam Type
entrance examination
(UPSEE(AKTU)/JEECUP/NEET)
15-Counseling no 16-Entrance Exam Year Sele
17-Rank obtained in entrance 18-Cut-off marks obtained in
0 0
examination entrance examination
19-Details of educational qualification (High School and other higher classes) of previous years
 Name of the
passing
no Educational qualification Integer Score percent Board/University/Affiliating
year
Agency

Personal details
20-Sub caste:
21-Residential Permanent
RANI MANDI ALLAHABAD UP - 211003
Address:
22-letter business address : RANI MANDI ALLAHABAD UP - 211003
23- Ration Card Number/Family
ID :
24-Disability type (if disabled):
(ii)-Disability Allowance (in
25(i)-Disability %
Rs.0):
(iv)-Disability Application
(iii)-Disability Certificate Number
Number:

Caste and Income Details

26-caste certificate no - 27-Date of Issue of Caste Certificate: -
28- Caste Certificate Application Form No:
29-Income from all sources of family of 96000 per
30-Income Certificate No. 453221062672
student (Rs 0): annum
31-Date of issue of income certificate: 13/09/2022 32- Income Certificate Application Form No: 221750010394789

Bank statement
33-Name of Bank: 34-Name of District:
BANK OF BARODA Kaushambi
(where student has account) (where the student has account)

RASOOLABAD URF
35-Name of Branch: 36-Student's Bank Account No: XXXXXXXXXX9867
KOLIHA
38-Name on the bank account
37-IFS Code: BARB0RASKOI SYED FAZAL HASAN
of the student:

Fee related details

39(i)-Approved Annual Non-Refundable Compulsory Fees: 59700

Last year details

PROMOTED WITH (ii)-Previous Year Examination
40(i)-Previous Year Exam Result: Semester system
MARKS System:
(iii)-Previous Year Marking Annual Exam Marking
System: System
(iv)-Integer of last year 2400.00 (v)- Previous year marks 1522.00
MADHU VACHASPATI
(vii)- Name of the educational SCHOOL OF
(vi)-Percentage of last year 63.42
institute MANAGEMENT
KOILAHA KAUSHAMBI

Registration number of application in Government of How to Register in Government of

renewed
India Scholarship Scheme India Scholarship Scheme
Indian Army / Paramilitary Force / State Police Force Current Status of Parent/Guardian
Type of Service being done in Uttar Pradesh Services:
Details of the certificate to be issued regarding the
service of parent/guardian
Destitute students from families affected by national calamity and other generally destitute students should be given first
preference/priority (according to the death certificate issued by the competent level).
(i). Status of parents/ legal
guardians/ guardians of the alive (ii). Date of death
student
(iv).Date of issue of death
(iii).Death Certificate No
certificate
(v). Cause of death
Form Submission Date:- 15/02/2024
Manifesto 3DD235F8050384F583EF4779091F1F15

I hereby declare that the above entries/information are correct and have been filled by me, I am not receiving any other scholarship from any other source and I am not serving
anywhere. If serving, the total annual income of me and my parents or guardians is less than Rs.2.00 lakhs (less than Rs.2.50 lakhs for Scheduled Castes/Scheduled Tribes). Annual
return has not been filed by my parents in income tax department. I have not taken admission in any other additional education session of this institution. I will duly comply with the
educational instructions of the institution and the minimum attendance of 75 percent prescribed for scholarship and fee reimbursement.
Along with any information given in the application form and attached residence and income certificate, if the annual income of my parents is more than Rs. Then I will refund the
amount of scholarship and fee reimbursement with penal annual interest. If I fail to do so, the department will be free to recover the amount received from me as revenue dues and
take legal action against me.
I, the holder of Aadhaar number, hereby give my consent to SW/ST/OBC/Minority Departments to obtain my Aadhaar number and Demographic/OTP for Authentication with UIDAI.
SUB-AUA (SW/ST/OBC/Minority Departments) has informed that my Aadhar number will not be stored/shared and will be submitted to CIDR only for the purpose of
SC/ST/Gen/OBC/Min Scholarship benefits.
I agree to obtain my Aadhaar number from the relevant departments for SC/ST/General Class/Backward Class/Minority Class Scholarships and get demographic and OTP
verification with Unique Identification Authority of India. My Aadhaar number will not be shared / protected and will be used for scholarship schemes

Date: ................................ Place: .............. ...................

Signature/thumb impression of parent Signature of the student
(Guardian in case of death of mother/father)

Admission Receipt-Session- (2023-24) - Class - - class - minority class

Appendix – 'F'
Registration Number:- 440510402200120
3DD235F8050384F583EF4779091F1F15

Receipt of Application Form for Dashamottar Scholarship and Fee Reimbursement

Mr./Mrs./Mrs./ SYED FAZAL HASAN Son/Daughter/Wife Mr. SYED ISHTEYAQUL HASAN
INSTITUTE MADHU VACHASPATI SCHOOL OF MANAGEMENT KOILAHA KAUSHAMBI COURSE MASTER
OF BUSINESS ADMINISTRATION
Original/self-attested copies of the following documents were obtained along with the application form
for tithe scholarship and fee reimbursement.
(To be checked and ticked by the office of the educational institution)
1- Photocopy of income certificate of applicant's mother/father/guardian (on prescribed format).
2- Photocopy of applicant's caste certificate (on prescribed format).
3- Photocopy of the receipt as proof of the fee deposited in the institution. Not required for
Scheduled Castes and Tribes.
4- If there is a gap between two classes, then a self-attested affidavit to that effect.
5- If the student is staying in a hostel then a copy of the fee receipt/certificate issued by the
hostel.
6- Photocopy of the passbook of the applicant's bank account on which the account number and
IFOS code is written.
7. Copy of high school mark sheet/certificate.
8. Certificate of passing previous examination.
1. Photocopy of mark sheet.
2. Photocopy of certificate.
(Signature of the officer/employee of the educational institution receiving the application form)
name:
Designation:
Date:
with the seal of the institution.