(To be filled in by the Candidate)
1. Nature of physical handicapped : Blind/Deaf/Orthopaedically Handicapped.
2. Name in full (in block letter) Shri/Smt./Km.
3. Postal address to which communication should be sent :-
4. (a) Are you a citizen of India?
(b) District and State which you belong :
(c) Whether Schedule Caste/Tribe:
5. Date of birth :
(in Christian era)
6. Name and address of the parents/
Name of the parent/guardian
guardian and relationship of the
guardian with the applicant.
Relationship of guardian
7. Total monthly income of both the parents/guardian:
8. Please state if you are earning an income Yes/No
If yes. please indicate
i. The source :
ii. The monthly amount :-
9. (a) Particulars of all examinations passed (commencing with the middle or equivalent examination)
| Name of Examination
|| Subjects taken
|| Name of Institution
|| Name of Board/University
(b) Percentage of marks obtained in the last examination passed:
(in the case of examination is misic, indicate division obtained)
10. Have you ever received Scholarship under the Scheme? Yes/No
If yes, indicate
i. the course/stage of study:
ii. period for which scholarship was paid:
iii. Sanction/Reference No. :
11. Please state whether you have undergone any training course at any training centre for adult blind/deaf
approved by Central/State Govt.
I. Course of study for which scholarship is now desired:
II. Date of commencement of the course:
III. Approximate date of termination of the course:
IV. Date of joining the present standard in the course during the current academic year.
12. For blind
Have you engaged a reader:
If yes, please indicate
i. Amount paid per month :
ii. Date of engagement :
13. Document attached:
I hereby declare :-
i. that I shall not accept emolument , scholarship, stopend, or any other financial assistance or grant in any other
form whatsever, except exemption from tuition fees , from any other course during the tenure of
Government of Manipur scholarship if awarded to me under the above scheme.
that I am in receipt of assistance to the tune of Rs
.. and in the event of award
of scholarship, I undertake to refund it from the month the scholarship is payable to me, to the source from
where I have received it, that during the tenure of scholarship, if awarded, I shall not receive any other
financial assistance, emoluments, scholarships, stipend or any grant in any form whatsoever, except the
exemption from payment of fees.
ii. that the statement made in the application are true to the best of knowledge and belief and that no material
information having a bearing on selection has been concealed or withheld.
Counter signature of Gazetted Officer of Central/
State Govt./M.P/M.L.A/Magistrate/Head of the Institution.
Signature of the Candidate
Counter signature of the guardian
in case the candidate is minor.
(To be filled in by the head of the Institution)
1. a) Is the candidate enjoying free board and/ or loging facility or any other concession in kind?
b) Id so, indicate the monthly amount equivalent to the concession.
2. Is the candidate residing in an hostel attached to School/College/Establishment? If so, date from which
3. a) Details of the nearest branch of Bank of India, or State Bank of India, or a subsidiary Bank affiliated to
the State Bank of India where Government business is transacted.
b) The designation of an officer in whose favour Demanf Draft may be remitted.
4. For Orthopaedically Handicapped.
i. (a) Is the candidate using any prosthetic appliance(s) and aid needed ?
(b) If so, please indicate the nature of the appliance(s) used.
ii. (a) Is the candidate using special transport to and from the institution?
(b) If so, please indicate clearly the mode of transport and the approximate distance travelled daily.
1. For Blind :
Has the candidate engaged a reader if so, the monthly amount paid to him/her and the date from
i. The information given by the applicant in Part-I has been checked and found correct.
ii. The institution is affiliated to the University of
.. and/ or is recognised by the
. and the course of study/ training is recognised by that University/
Signature of the Head of the Institution
Name (in block letters)
Seal of the Head of the Institution)