Coal India Scholarship Scheme for BPL Students For the Academic Year ______________ Please download the application form and sent the hard copy after filling the same along with relevant documents to the address mentioned at the end of the form. Coal India Scholarship Application form Coal India Scholarship Scheme for BPL Students – Application Form for the Academic Year _______________________ Applicant must fill all the details in the application form neatly handwritten or in capital letters if any field is not applicable to the applicant please write not applicable Personal Information *Paste a recent passport size photo of the candidate attested by Name ________________ Date of Birth: DD___ MM___ YYYY________ Nationality ____________ Gender: - Male - Female Marital Status: - Married - Unmarried Religion ______________ Caste: - Gen - SC - ST - OBC (Non-Creamy Layer) If yes: Certificate No ______ Date of Issue ________ Issued by ____________ Physically Challenged / Handicapped? - Y - N If yes, degree or % of disability ________ Certificate No ________ Date of Issue ________ Issued by __________ BPL Card No ____________ Date of Issue __________ Issuing Authority ________ Father’s Name ___________ Occupation ___________ Mother’s Name __________ Occupation ___________ Husband’s Name __________ Occupation ___________ Address for Communication / Correspondence ___________________________________________________________________ Region _______________ State __________________ Country ___________ Pin Code ______________ Permanent Address (if different from communication address) Street _________________________________ Region _______________ State __________________ Country ___________ Pin Code ______________ Contact No: Tel No (with STD code) _____________ Mob No ______________ E-mail Address ________________ Alternate e-mail _______________ Identification Proof ___________ (pick from list Voter I-Card, Driving License etc.) ID No. __________ or License No __________ Has any FIR ever been lodged against the applicant? – Y – N If yes, provide details here: FIR No. __________ Police Station __________ Proof of being “Land Oustees” or Displace Person” Photo Identity Card No. _________ Issuing Authority __________ Academic Details (present) Course Name _____________ Specialization, if any ____________ Name of Institute ____________ Address of Institute ___________________________ Contact Person __________ Contact No. _____________ Duration of the Course _______ Form of course (Semester-wise/Yearly ) ____________ No. of Semesters / yrs (whichever applicable) ________ Admission details: Date of admission dd/mm/yy Current semester / yr of study ___________ Student I / Roll No. ___________ Total Annual Course Fees (including all expenditure) __________ If the course is in yearly form, provide details of the Annual estimated expenditure for the course: Tuition fees _________ Books __________ Others ____________ If the course is in semester form, please provide details for each semester as applicable Tuition fees _________ Books __________ Others ____________ Is the student availing hostel & mess facilities? –Y – N If yes, Hostel Charges per yr or per semester whichever applicable _________ Mess Charges per yr or per semester whichever applicable ___________ Educational Details Please provide the academic qualification in reverse chronological order starting from latest: Sl. No Name of Degree Speclzn. / Subject Institu te Universi ty From (mm/y y) Yr of passing (mm/yy) Overa ll % Divisio n/ Class Rank/ Grade Note: Convert CGPA into % as per AICTE norms Please provide the rank in the qualifying entrance examination for course in which you are enrolled Examination Name _________ Conducted by __________ Rank ____________ Other Extra-curricular Activities (only state / national / above level): NCC Certificate ______________ Other ___________ (Please mention) Any other academic distinctions, grants, scholarships, prizes etc. received by the student __________________________________ Describe yourself as a person, sharing your dreams, aspirations, life-goal etc. (not more than 200 words) __________________________________ *Declaration: I ___________ hereby declare that the information provided above is true and correct in all respects to the best of my knowledge and belief. If any of the information furnished above is found to be incorrect at any stage, my application for the scholarship is liable to be cancelled. Signature: ___________ (student) Full Name: __________ Signature of Father/Mother/Guardian ___________ Date: _________ Place: _________ Forwarding by the Head of the Institute I solemnly declare that the Institute / College ___________________ is duly recognized by Central Govt. / State Govt. I also declare that the above information furnished by the candidate Shri / Smt. ______________ is true and correct in all respects to the best of my knowledge and available Office records. I therefore, recommend his/her candidature for the Coal India Scholarship. Signature ___________ Name __________ Designation __________ Date _________ Place _________ List of attested enclosures along with Application form Seal of Institute ____________ Date of Birth Certificate / DOB proof of applicant Photo identity proof of candidate (voter I-card, driving license etc.) Residential proof of applicant’s father / legal guardian – Telephone Bill, Electricity Bill Mark sheets of candidate – Matric (10th std.) onward Proof of qualification in course and rank in the qualifying examination Proof of admission in the institute Proof of annual financial expenditure for the course Mark-sheet of the candidate if any semester is completed BPL Card Caste Certificate, if applicable Physically Handicapped / Physically Challenged Certificate if applicable Domicile Certificate of candidate (issued by competent authority) Forwarding letter by the Head of Institute in the prescribed format Note - The applications duly completed in the prescribed format along with the required enclosures (as mentioned above) should be submitted to the concerned Director / Dean / Head of the respective institutions, who in turn will scrutinize the applications as per CIL Scholarship scheme and send the same along with the Forwarding letter given with the Application Form to the following address. Chief General Manager (Welfare), Coal India Limited, Coal Bhawan, 10, Netaji Subhas Road, Kolkata – 700001 Ph. No. 033-22488099 Fax No. 033-22435316