PART-II

CENT VIDYARTHI
(For Common Application Form,Guarantors Consent Letter & Acknowledgement-Please fill PART-I.)
BASIC INFORMATION

Sl Particulars
a. Proposed course of Study

Details

b. Duration of Course

Years

Full time

Part time

c. Name and address of the College /

Institution in which the student intends
to join.

d. Name of the University/Recognised

Authority to which
institute is affiliated.

the

college/

e. Has the student been admitted into the

f.
g.
h.
i.
i.

above College /Institute / University

or accepted for the Course? If so,
certified
copy
of
admission/
acceptance Letter should be attached
Is the applicant attending any college
or Institute at present? If so, furnish
full particulars.
No. of earning members in the Family
& their total income.
Whether the student has any working
experience? If yes, please give details.
Whether the student will take up any
part-time employment during study? If
yes, please give details.
Year of retirement of father Guardian
(if in service only)
2
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CENT VIDYARTHI
STUDENTS ACADEMIC RECORD:
Name of the examination from SSC or equivalent onwards
Name
of
the
School/ College
Medium
of
instruction
Examination
authority
Month & year of
passing
Whether passed in
the first attempt
Aggregate marks
first attempt
Out of total marks
Percentage
of
marks
Rank/Class/Div
obtained
Scholarship/ Prizes
won for academic
distinction.
(Certified copies of the list of marks of all the above exams should be enclosed)
PARTICULARS OF FINANCIAL REQUIREMENT OF THE COURSE
Studies in India
Rs.
Studies in abroad
Rs.
Admission fee
Total fees for ______ per year
Term Fee for ___years
Books, stationery, instrument
& equipment
Books, stationery,
Boarding & lodging @
instruments,
___________ per year for
equipment
_____________ years
examination fees
Boarding & loadging
Total i.e. Equivalent in Rs.
@ Rs.______ per
month for ________
years
Total (enclose
Air passage (one way only)
evidence)
Total (enclose evidence)
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CENT VIDYARTHI
SOURCE OF FINANCE:
1.
2.
3.
4.
5.

Non repayable scholarship(s) at Rs._____________ p.a. for

____________ years
Loan scholarship(s) and or other repayable financial assistance
from other sources
Contribution of Parent/ Guarding and /or other Members of
the family / relatives towards total expenses
Amount of loan required from the bank
Earning of the student(if any)
Total

Rs.__________________
Rs.__________________
Rs.__________________
Rs.__________________
Rs.__________________
Rs.__________________

Particulars of Insurance Policy (ies) (In the case of father/ guardian/ applicant only)
Names of the insured Policy No
Date
Date(s) of
Amount of
Date of last
Maturity
yearly
premium
premium
paid

ADDITIONAL INFORMATION TO
UNDERTAKING STUDIES ABROAD
a.
b.
c.
d.
e.
f.

BE

FURNISHED

BY

STUDENTS

Amount of foreign exchange required.

Foreign currency
Rupee equivalent
Have you obtained the necessary passport,
/visa etc? Yes/No.(if yes, give reference)
Do you intend to take up any part time
employment during the course of studies
abroad? If so, give particulars.
What are your likely Prospects on your return
to India?

DECLARATION: We hereby declare that the information furnished against the foregoing
items is true to the best of our knowledge and belief.
We also undertake to inform the bank immediately any change in our
employment details, address, telephone number including mobile no. etc. for both local
and permanent address,
Signature of Father/Guardian
Place

Signature of student

Date

Signature of Guarantor (if any)

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