APPLICATION FORM 2011

NSF 11 :

1) POST GRADUATE STUDIES TO BE PURSUED IN : Name of the Course / Degree : .. Subject : .. Specialisation :. 2) PERSONAL DETAILS :

Recent Passport Size Photograph (Taken in last one month)

Name : (Mr./ Ms./ Dr.) : ................................................ First Name Middle Name Surname Date of Birth : . Nationality : Country of Birth : Passport No ..

Permanent Address : .. . .. Tel. No. (Res.) : . Mobile : .. Tel. No. (Off) : E-mail ID : .

Address for Communication : . Tel. No. (Res.) : . Mobile : .. Marital Status : Married + Single + NOTE : Please fill up the form in your own handwriting Before submitting, ensure that the application is complete in all respects Tel. No. (Off) : E-mail ID : .

3) FAMILY BACKGROUND Family Member Name Age Educational Qualification Occupation / Designation Name & Address of Company Gross Income per annum

Father

Mother

Brother(s)

Sister(s)

Spouse

Has your education so f ar been f inanced by a person ot her t han your parents, or by a scholarship from a Trust or Foundation?

Yes

. ..

No

If yes, please mention name of the person / Trust / Foundation that f inanced your education so far : Relationship of the person with you: Amount of aid received per year:

4) EDUCATIONAL BACKGROUND Give details of your educational qualifications: Year of Commencement Qualification % of Marks or Grade Main Subjects Studied Year of Completion Scholarships, Awards, if any

Name of School & Board / Name of College & University

SSC or Equivalent

HSC or Equivalent

Bachelors Degree : (Please specify name of the degree & subject)

1st Year

2nd Year

3rd Year

4th Year

5th Year

Masters Degree : (Please specify name of the degree & subject)

1st Year

2nd Year

Any other Course (please specify)

Have you previously studied in any country other than India ? If yes, please give the following details : Course of Study Undertaken Outside India Name of the Institution

Yes

No

Source of Funding

Year of Study

5) SCORES ON QUALIFYING TESTS, WHERE APPLICABLE Name of Test GRE

Verbal Quantitative Analytical Writing

Test Date

Score

Percentile

Name of Test TOEFL IELTS GATE CAT Any other

Test Date

Score

Percentile

GRE Advanced GMAT

6) NON ACADEMIC INTERESTS / HOBBIES / TALENTS ACTIVELY PURSUED Year(s) Brief Description of the Activity Pursued Prizes, if any

7) AWARDS AND SCHOLARSHIPS Year(s) Name of the Award / Scholarship Awarding Body

8) RESEARCH EXPERIENCE, IF ANY

Give details of any research work that you may have undertaken :

Year(s)

Name of the Institution / Organization

Title of the Research Project

Whether Individual / Group

9) WORK EXPERIENCE, IF ANY

If you have been in employment, give details of the employment :

Year(s) From To

Name & Address of Employer / Organization

What does the Organization do ?

Position Held / Designation

Job Description What are your Duties & Responsibilities?

Gross Income pm

10) HAVE YOU BEEN INVOLVED IN ANY WORK / ACTIVITY / PROGRAMME TO CHANGE / IMPROVE THE SOCIETY / COMMUNITY ? YES

NO

If yes, give details of the work / activity / programme, and your role in it :

11) SCHOLARSHIP FOR POST GRADUATE STUDIES a) Have you applied, or intend to apply for any other scholarship for your proposed P G Studies ? Yes

No

If Yes, please give the following details : Whether Loan or Gift Scholarship Status of the Application Amount Promised / Expected

Name of the Trust / Foundation

b) Please tick the source(s) from which you got inf ormation about the Narotam Sekhsaria Foundation ( NSF ) Scholarship : Internet

Newspaper

Former Narotam Sekhsaria Scholar

College / University

W ord of mouth

Education Expo

Please specify details of the source(s) ticked:

c) Have you earlier applied to the Narotam Sekhsaria Foundation for a scholarship for Post Graduate Studies ? Yes

No

If Yes, please mention the year

12) PROPOSED PROGRAMME OF STUDY AND INSTITUTION

a) Give details of the Course of Study and the University / Institution applied to for your proposed programme of study in Website Address Admission Status ** Applied / Admitted Degree Sought Subject & Specialization Duration of the Course Financial Aid ** from the University

S.No.

Name of the University / Institution

**

Please enclose evidence of your application / admission to the above-mentioned institution(s), and offer of financial assistance

b) Give details of the estimated cost of the course per annum

Tuition Fee p a Living Expenses Miscellaneous Costs TOTAL COST p a

Item of Expenditure

Currency

US $ / GBP ( ) /

Indian Rupee Equivalent

13) GIVE A BRIEF WRITE UP ON THE PROJECTS / RESEARCH YOU HAVE WORKED ON ( Not more than 300 words)

14) WRITE A BRIEF ESSAY ON WHY YOU CONSIDER YOURSELF WORTHY OF THIS SCHOLARSHIP ( Include a mention of your career plan; the opportunities available for the proposed course of studies in India; and the contribution you hope to make to improving the the quality of life in India after completing your studies )

15) REFEREES You are required to submit with your application, reference letters in a sealed envelope from two referees, at least one of whom is an academic referee. The referees should be other than relatives, t hey must hold posit ions of responsibilit y, and t hey should have known you f or at least three year s. One of t he ref er ees must be a person who is able to comment on your competence to cope with the academic demands of the course you are applying fo r. Please enter details of your ref erees below:

(1)

Name Designation Address for Correspondence

Tel. No. Capacity in which known

Mobile

E-mail Duration for which known

(2)

Name Designation Address for Correspondence

Tel. No. Capacity in which known

Mobile

E-mail Duration for which known

16) APPLICATION FEE

Application fee of Rs 300/- paid by

Cash / MO no__________

DD no ________

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17) DECLARATION

I cert if y that the inf orm at ion g iven in t his applicat ion is corr ect and com plet e t o t he best of m y knowledg e. I understand that t he loan am ount awar ded is t owards a p er c e n t ag e of my t uit ion f ee only, and does not cover t he t ot al cost of t he course. I also understand t hat , if select ed, I wil l have t o sig n an MoU and agr ee t o r epay t he loan am ount as per t he r epaym ent schedule of the Narot am Sekhsari a Schol arshi p Programm e. I wil l also have t o t ak e a Lif e I nsur ance Policy and assig n the sam e to t he N S Foundat ion. Furt her , I accept t hat on com plet ion of my st udies, I would cont inue t o associate wit h t he Nar ot am Sek hsar ia Scholarship Pr ogr amm e, and would be wil ling t o t ake t he r ole of m ent or ing others . 1) I h e r e b y a c k n o w l e d g e t h a t t h e d e c i s i o n o f t h e N S F o u n d a t i o n i s f i n a l w i t h r e g a r d t o awar ding and / or cont inuing m y scholarship. 2) If I am unable to repay the scholarship loan within the prescribed time, the N S Fo un d at i on wi l l h a ve t h e r ig h t t o ho l d m e, as we l l as m y p ar e nt s an d / or m y g u ar ant or r e s pon s i b l e f or t h e r e pa ym e nt . Da t e : _ __ _ __ _ __ _ _ ___ _ _ _ Si g na tu re of App li c an t : _ _ __ _ __ _ __ __ _ _ __ _ __ _ __ _ __ _ __ _ __ _ _ __ _ _ Na me of t h e Ap pl ic a nt i n f ull (in bl oc k l ett er s) : _ __ _ __ _ __ _ __ _ __ _ __ _ _ __ _ __ _ __ _ __ _ __ _ __ _ _ __ _ I have r ead t he above declarat ion and I underst and t hat, if t he applicant f ails t o r epay t he loan am ount as per t he r epaym ent schedule, I will be liable t o r epay t he sam e. Da t e : _ __ _ __ _ __ _ _ ___ _ S ig n at u re of P a ren t/ Gu a ra nt o r : _ _ __ _ __ _ _ __ _ __ _ __ _ __ _ __ _ __ _ _ __ _ _ Na me of P a r en t/ Gu ar an t or i n f ul l (i n b lo c k let ter s) : _ __ _ __ _ __ _ __ __ _ _ __ _ __ _ __ _ __ _ __ _ __ _ _ __ _ Re l ati o ns hi p of Gua ran t or , if ot h er t h a n P are n t, w it h t he Ap pli ca nt : _ __ _ __ _ _ __ _ __ _ __ __ _ _ __ _ _

PLEASE ENCLOSE THE FOLLOWING WITH YOUR APPLICATION

1. Attested copies of : (a) All mark sheets and degree certificates in support of your educational qualifications (b) GRE / GMAT / TOEFL / IELTS / GATE / CAT score cards, as applicable (c) Award letters of scholarships / awards received, as mentioned under Item 7 2. A copy of your application to the university and / or offer letters confirming your admission. 3. Attested copy of the first 4 pages of your passport. 4. A self-addressed, stamped envelope to inform you the outcome of your application. Please note that only short listed candidates will be called for an interview. However, all applicants will be informed of the outcome of their application.

Please send your application, complete in all respects, at the following address on or before 18

th

March 2011 :
NAROTAM SEKHSARIA FOUNDATION
102, Maker Chambers III, Nariman Point, Mumbai 400 021.Tel.2282 4589 / 2282 8502 / 2282 4705 Fax: 2282 9534 E -mail: [email protected]

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