Details of Online Application Form for Post-Dec Scholarship and Fee Reimbursement (New)

Session - (2024-25)
(For Deposit in Educational Institute)
Date of Print:- 03/01/2025
Registration Statement
District Name: AGRA
Name of Education Institute : DR. BR AMBEDKAR UNIVERSITY, AGRA
Registration Number: 150290502403823
Name of Student: Ajay Anant
Changed name of student if:

Name of Father / Husband: C/O: Avinash Kumar Dubey

Mother's Name: PRATIBHA DUBEY
Religion: Hindu
Class/Ethnic Group: General class
Date of birth: 23/06/2006
Gender: MALE
Mobile, Tel No : XXXXXX4472 ,
Email
High School Board UP BOARD Year of passing high school 2022
Name and Address of
High School Board Ka Serial
1220022840 University/Institution
No
from where High School passed

Academic Statement
1-Name of Course: B.COM VOCATIONAL
2-Course Why Branch: B.COM VOCATIONAL
3-Type of Course: Regular 4-Class Year and Duration: 1,3
5-Entry is based on Lateral Entry NO 6-Residential / Day Student:
7-Date of Admission in First 8-Date of admission to the
Year of Course: current session of the course:
9-Registration No. in 10-Name of
Dr. Bhimrao Ambedkar
University/Board/Affiliating University/Board/Affiliating
University, Agra
Agency Agency:
Admission to 11th Vocational
Course is based on Class 12 12-Course Key Eligibility: Intermediate
Marks/Merit:
Admission to 13th current
course is through Entrance Test 14-Types of Entrance Exams
(UPSEE(AKTU)/JEECUP/NEET)
15-Counseling no 16-Entrance Exam Year
17-Rank obtained in entrance 18-Cut-off marks obtained in
exam entrance exam
19-Statement of Educational Qualification (High School and other higher classes) for last years
Name of the
passing receipt
Number Educational Qualification Integer Percentage Board/University/Affiliating
year number
Agency
 1 High school 2022 600.00 396.00 66.00 UP BOARD
2 Intermediate 2024 500.00 263.00 52.60 UP BOARD

Personal details
20-Sub-caste:
21-Residential Permanent
-
Address:
22-Letter Transaction Address : -
23- Ration Card Number/Family
ID :
24-Type of disability (if
disabled):
(ii)-Disability Allowance (in Rs.):
25(i)-Disability %

(iv)-Disability Application
(iii)-Disability Certificate Number
Number:

Caste and Income statement

26-Caste Certificate No - 27-Date of Issue of Caste Certificate: -
28-Caste Certificate Application Form No:
29- Income from all sources of student / Annually 30-I Certificate No. 151241023941
student's family (Rs 0): 120000
Date of issue of 31-I Certificate: 28/12/2024 32-I Certificate Application Form Number: 241460010193118

Bank statement
The amount will be paid from Aadhaar No. to the Aadhaar seeded bank account. Bank account should not be registered.

Statement of Charges
39(i)-Approved Annual Non-Refundable Compulsory Fees: 6335

Form Submission Date:-sion Date:- 02/01/2025

Declaration letter D2B1576DE884544B3DBB93981FA41CC9

I hereby declare that the above entries/instructions are true and 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 returns
have not been filed by my parents in Income Tax Department. I have not taken admission in Shiksha session anywhere else apart from this institution. I shall duly comply with the
academic instructions of the institution and the minimum attendance of 75 percent prescribed for scholarship and fee reimbursement.
Any notice given in the application form along with attached residence and income certificate if the annual income of my parents is more than Rs 2.00 lakh (Rs 0-2.50 lakh for
Scheduled Castes/Scheduled Tribes) and other records are incorrect. He/she shall refund the scholarship and fee reimbursement amount with penal annual interest. If I fail to do
so, the Department shall 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 consent to get my Aadhaar number for SC/ST/General Class/Backward Class/Minority Class scholarship to concerned departments for demographic and OTP authentication 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 Mark of Mother/Father Signature of the student
(Guardian in case of death of mother/father)

Admission Receipt-Session-(2024-25) - Class - General Class

Appendix – 'F'
 Registration Number:- 150290502403823
D2B1576DE884544B3DBB93981FA41CC9

Receipt of application form for Dashamottar Scholarship and Fee Reimbursement

Mr./Mrs./Mrs./Ajay Anant Son/Daughter/Wife Mr. C/O: Avinash Kumar Dubey
INSTITUTE DR. BR AMBEDKAR UNIVERSITY, AGRA COURSE B.COM VOCATIONAL
Original/Self-attested copies of the following documents along with the application form for Dashamotta
Scholarship and Fee Reimbursement have been obtained.
(To be checked and ticked by the office of the educational institution)
1- Photocopy of I certificate of applicant's parent/guardian (on prescribed format).
2- Photocopy of caste certificate of applicant (on prescribed format).
3- Photocopy of the receipt in the form of fee deposited in the institution. Not required for
Scheduled Castes and Tribes.
4- If there is a gap between the two rooms then a self-attested affidavit to that effect.
5- Copy of the fee receipt/certificate issued by the hostel if the student is staying in the hostel.
6- Photocopy of the passbook of the applicant's bank account on which the account number and
IFS0 code is printed.
7. Photocopy 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)
Noun:
Designation:
Date:
With institution key seal.