Csss-renewal [f-11] Scholarship Form 1k42m

10/26/2014

CSSS-RENEWAL [F-11] Scholarship Form

CENTRAL BOARD OF SECONDARY EDUCATION SHIKSHA KENDRA, 2, COMMUNITY CENTRE, PREET VIHAR, DELHI-110092 CSS SCHOLARSHIP - 1 RENEWAL OF YEAR 2013 FORM: F-11 To, The Assistant Secretary (Scholarship), 7th Floor, CBSE, Shiksha Kendra, 2, Community Centre, Preet Vihar, Delhi-110092

Form No.: Registration No. of CSS Scholarship Class XII Roll No. Year of ing

R2013100596 13005121 6629684 2013

1. Applicant Name: UPENDRA KUMAR SAHU Father's/Guardian's Name: S L SAHU Category O DOB 20/04/1996 Gender M 2. How much amount received till date against the CSSS award: 10000 3. Address of the Institution : Type of Institution :

NATIONAL INSTITUTE OF TECHNOLOGY, RAIPUR (C.G), Have you changed the NO Raipur, Chhatisgarh, Email: College/Institution of Study Name of the Institution where course NIT Central Govt is being pursued: RAIPUR

4. Have you changed the Stream/Course of Study NO Mode of Study : REGULAR MODE Name of the Current Course & Duration : B.TECH Duration:4Years Pattern of Examination : SEMESTER Subject of the Course : UG DEGREE Course Approval : AICTE Type of Programme : ENGINEERING 5. Aggregate marks obtained in Annual Examination first/second/third year (which is applicable) (if result is in grades, 77.9 equivalent percentage is required from the college/university) 6. Address for Correspondence: QR. 29/C, STREET-36, SECTOR-04 Telephone No. with STD (0788)2224791 BHILAI NAGAR Code: Mobile No.: 9424121652 Durg, Chhatisgarh Pin: 490001 E-mail ID: [email protected] 7 Is the candidate in receipt of any other scholarship from State Government No or other institution or person ? 8 Adhaar Card/Enrollment Number of Applicant (Optional) 9. Particulars of Savings Bank of Applicant a) Number 33276062151 c) Address of the Bank INDIRA PLACE BHILAI BHILAI NAGAR b) Name of the Bank STATE BANK OF INDIA d) RTGS/NEFT Code SBIN0000574 10. Cheque Number of the Photocopy of Cancelled Cheque Attached (Optional) 632441 I, UPENDRA KUMAR SAHU certify that the statement made by me in this form is correct. I declare that as I receive this Scholarship, I shall devote my full time to the course of study. I shall maintain good discipline and not indulge in ragging activities and that I shall not receive any other stipend/scholarship from any other source. If inadvertently payment will be released by the Board, I will refund without any delay. Signature of candidate VERIFICATION OF THE FORM BY THE HEAD OF THE INSTITUTE/COLLEGE (ING REPORT) This is to certify that UPENDRA KUMAR SAHU S/o, D/o, W/o enrolled in NIT RAIPUR for the course B.TECH has ed in all the subjects in the Semester/Annual examinations held in ___________ (Month& year) of the Course and has scored not less than 60% marks. He/She has maintained not less than 75% attendance, good discipline and has not involved in ragging activities.

Place ______________ Date: ______________

Signature with Stamp Of Head of the Institution ________________________________ Name & Designation ________________________________ Tel. & Mobile No. ________________________________ Email ID: ________________________________ Seal

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