Account Code No.

_________________

Indian Institute Of Management, Nagpur

SPECIAL NEED-BASED SCHOLARSHIP FORM (SNBSF)
(To be filled in and signed by the applicant. Please keep a photocopy of the duly filled form and
attachments for your reference)

____________________________________________________________________________________________________

IIM NAGPUR IS PLANNING TO INITIATE SNBS. TO SET THE PARAMETERS / NORMS FOR ELLIGIBILITY FOR
THIS SCHOLARSHIP, THE SURVEY OF EXISTING BATCH HAS BEEN INITIATED. KINDLY FILL THE
ATTACHED FORM AND SUBMIT IT TO SAO OFFICE BY FEB 17, 2017.

KINDLY NOTE THAT THE FINAL DECLARATION OF THE SCHEME WILL BE INFORMED AFTER THE
APPROVAL OF COMPETENT AUTHORITIES.

___________________________________________________________________________________________________

Personal Information

1. Name of the student

(In block letters)

Last First Middle

PGP I (Batch 2016-18) Roll No._________________

2. Phone No.: Land Line (________) _____________ Mobile __________________________

STD code

3. Present Address

4. Permanent Address

5. D.O.B

6. Marital Status: Single/Married

(a) If yes, what was the date of your marriage?

(b) If yes, please provide the following details:

What was the income of your spouse during 2016-17 in case

you were married for the whole or part of 2016-17? `

(Note: Income here means income from all sources prior to any deductions allowed by Income Tax
Act)

8. Were you working? If yes, since how long?

Also indicate the salary being drawn and the savings from your income

Salary: ` Savings: `
9. Indicate the amount of educational loan you intend to take for your studies (for 2 years) at IIMN
`____________
 Amount availed so far (for 1st year) ` _______________

Name of the Bank ___________________________________________ Branch______________________________

Loan Account No. _________________________ MICR Code ________________________IFS Code _____________

Rate of Interest per annum________ Terms related to Interest payment

___________________________________

Terms related to principal repayment _______________________________________________________________

Address of the bank______________________________________________________________________________

Parental Information:

1) Names of your Father/ Guardian : ________________________________________

Mother/Guardian : ________________________________________

2) Age of your Father/ Guardian : ________________________________________

Mother/Guardian : ________________________________________

3) Educational Qualifications Father/ Guardian :

________________________________________
Mother/Guardian : ________________________________________

4) Occupations of your: Father/ Guardian : ________________________________________

Mother/Guardian : ________________________________________

5) If any of the parents/guardians is in service, give:

i) Designation of
Father/Guardian : ________________________________________
Mother/Guardian : ________________________________________

ii) Address of employer :

_____________________________________________________________________

___________________________________________________________________________________________

iii) No. of years in service : ___________________________

(Note: If retired, give details of previous job in items i), ii) and iii) above

iv) Gross annual salary during 2016-17

Father/Guardian`____________________
Mother/Guardian `____________________

v) Income from other sources during 2016-17

Father/Guardian`____________________
Mother/Guardian `____________________

vi) Total income from all sources during 2016-17

Father/Guardian`____________________
Mother/Guardian `____________________ Total `_________________
 6) If any/both of the parents/guardians is/are self-employed, give:

A. Father/Guardian
i) Nature of business: Sole proprietor/Partner : __________________________________

ii) Indicate the name of the Company : ____________________________________________________

iii) Annual Income: YEAR------> 2016-17 `___________________

B. Mother/Guardian
i) Nature of business: Sole proprietor/Partner : __________________________________

ii) Indicate the name of the Company : ____________________________________________________

iii) Annual Income: YEAR------> 2016-17 `___________________

7) TOTAL ANNUAL PARENTAL INCOME FOR THE YEAR 2016-17: (5vi + 6Aiii & Biii)
`___________________

8) Parents Principal Assets and Liabilities

i) Life Insurance Policy

Name of the insured Year in which Face Value of Annual Loan Present value
policy taken the policy (`) Premium (`) outstanding, after
if any (`) deducting
loan
outstanding (`)

a) Father/Guardian
b) Mother/Guardian

c) Others

ii) Immovable Properties

House property (Indicate location and Present sale value Unpaid mortgage Difference (a-b)
address) (a) (`) (b) (`) (`)

Total

Agricultural land, No. of acres (Indicate Present sale value Unpaid mortgage Difference (a-b)
place, location, wet/dry, etc.) of land (a) (`) (b) (`) (`)

Total

Other real estate Present sale value Unpaid mortgage Difference (a-b) (`)
of the property (a) (b) (`)
(`)
 Total

iii) Movable Properties

i. Capital value of the share holdings (if doing business) `

ii. Market value of other investment - shares, bonds, vehicles, etc. `
iii. Savings (current account/fixed and bank deposits) `
iv. Provident Fund `
Total `

9) List all the members of your family including the earning members with their monthly incomes
and all dependents on the incomes.

Sl. Name Age Relationship Monthly Occupation Income Tax Account

No. with Income No.
the student (PAN No.) and Area
Code

a)
b)
c)
d)
e)
f)

Signed by Candidate:

Date: