KERALA STATE COUNCIL FOR SCIENCE, TECHNOLOGY & ENVIRONMENT PRATHIBHA SCHOLARSHIP. A scheme for identifying and nurturing talents in S&T

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1 FORM- B KERALA STATE COUNCIL FOR SCIENCE, TECHNOLOGY & ENVIRONMENT PRATHIBHA SCHOLARSHIP A scheme for identifying and nurturing talents in S&T APPLICATION FORM- B (For Prathibha Scholars enrolled for 1 st year M.Sc/4 th & 5 th year Integrated M.Sc /1 st & 2 nd year of Integrated Ph.D Course) FOR OFFICE USE ONLY Registration number of Prathibha Scholar Duration of BSc/Integrated M.Sc Course & Subject of study Year of enrolment [for M.Sc Course/ 4 th year of Integrated M.Sc Course/1 st year of Integrated Ph.D course.] & Subject of study Year of current Application PART -1 (To be filled up by the applicant) 1. Full name of the candidate : (To be filled in Capital Letters) Affix recent passport size color photograph attested by Gazetted Officer 2. Address for communication : 3. Gender- (Male/Female) : 4. Date of birth : 5. Caste category (General/SC/ST): (Enclose relevant documents of proof for SC/ST Candidates) 6. Place of birth (include State and Place): (Enclose relevant documents of proof) 7. Father s name & occupation: 1

2 8. Mother s name & occupation: 9. Details of qualifying examination): (Please enclose copies of certificates and mark list attested by a Gazetted Officer) Name and address of college where the student completed his/her B.Sc. Degree Course or undergoing Integrated M.Sc. course Year of Passing B.Sc.Degree Examination Year of Subjects Study 1 st Year Maximu m marks Marks Scored % of Marks scored Grade if any 2 nd Year 3 rd Year Overall 2

3 10. Details of course for which scholarship is being sought: (M.Sc./Integrated M.Sc. Course) i. Name and address of college where the student is now admitted to the M.Sc Course or continuing 4 th year of Integrated M.Sc. course Tel: ii. Name of class/course/subject : iii. Duration of class/course : iv. Academic year : v. Date of admission to the course : vi. Admission number of the student : 11. Beneficiary account details for receiving scholarship through E-payment. Beneficiary Name (as in Bank records) Beneficiary Account No. Beneficiary Address Name of Bank Drawee Branch (Place) IFSC DECLARATION BY THE STUDENT 1. I am not availing any other scholarship for the present course of study. (SC/ST students may mention if they are in receipt of lumpsum grant). 2. I have availed Prathibha scholarship for all three years of my Undergraduate Degree course/first three years of Integrated M.Sc course. 3. I shall abide by the terms and conditions for sanction of the PRATHIBHA SCHOLARSHIP SCHEME. 4. I undertake that all the information provided is authentic to the best of my knowledge. Date: Place: Name & Signature of the student 3

4 PART II To be filled by the Head of the College/Institute where the applicant is admitted for M.Sc./Integrated M.Sc. Degree Course. 1. Details of college/ institution i) Name & Address of the College/University/institute (where the applicant is admitted for M.Sc./Integrated M.Sc. Degree) Tel: Fax ii) Name of the subject/branch opted for the course : iii) Date of admission to the course : iv) Admission number of the candidate : 2. Verification certificate (to be furnished by the Head of College/Institute/ University where the applicant is admitted for M.Sc./Integrated M.Sc. Degree Course) i) It is certified that the information filled in the above mentioned columns by Shri/Kumari S/o / D/o Shri... who is admitted to M.Sc Degree /Integrated M.Sc Degree Course * for the academic session ii) iii) in. (Name of College/University/Institute) is authentic. (*Strike whichever is not applicable) Certified that he/she is a fresher admitted in the college during the current academic year Certified that the Character and Conduct of the student are good. Head of the Institution Place: Date: Signature Name & Address: (Seal) 4

5 CHECK LIST OF DOCUMENTS TO BE ATTACHED 1. Duly filled up application form in the prescribed format (Form -B) 2. Attested copy of consolidated mark list of B.Sc. Degree Course / copies of mark lists of first 3 years of Integrated M.Sc. Degree Course. 3. Status Verification Certificate signed by the Head of the Institution where the student is undergoing the Degree Course/Integrated M.Sc. course. 4. Terms and Conditions in Stamp Paper worth Rs. 50/- duly signed. 5. Advance receipt in prescribed format duly signed by the student. 6. Undertaking by the student that he/she will not receive any other Scholarship for the current course of study. 5