2625, THE XA\/ERY EITGINEERING COLLEGE, MECHERI,SAIEIIIT .

636453
SCHOLARSHIP STUDENT DECLERTION FOR,IIT
ACA,DEMIC DETAILS
AGRI/ BME/ CTI/IL/ CHEM I EEE I E.E I
2025-26 IITECH/AIDS/CSE/IT
F.eshlr yre / lac.avRenemL/rnsr.rrasre.
t/tln/)v

PERSoNAL DETAILS I All Details Fill oily itr capital Lettels )

Farler / cutrdiml! e

sc/sT/scc
All Deteils as pe. SSLC/HSC Mark sheet
PERMENANT ADDRESS AADHAR SEEDED BANK DETAILS

Xerox Copy of Balk Pass Book Front Page

( Account l{rEber must be visible I
HoSTEL DETAILS I college Hostet stutlents otrty I

(1).I de.lde fiar ahore memioned detalls de hej.or.e.tdd he, co..edad complete.
(2). I herehy assu.e fiar I win pay the schoLarship amoum completely to our Instiruion within 7 days lrcm the date ol amomt credited ln to the hail<

stuilert siEratur.

9 Lasr Semesier v k Sneet

4.community certficare

s.12th s.hool Atenddce

r If Eai€lt r.r&i!E i! cowt..r.h / Pe ior hol.l.r t. 6. pr.duc€d salaiy ..rtifrcat€ lor) Barr stateEert.
cta$ircf,arr$ are asled to werify tf,e a6.we tletaib e .locuoerk geLre .ir!i!E.
 1
gg.$1.u.p.74&75

piltipr@ gtra
GOVERNMENT OF TAJUIL NADU
eUdsundlui uiuurn ugngguflant Eal$ElaDp
AI'I DRAVIDAR AND TRIBAL WELFARE DEPARTMENT
post Matrlc Scholarshlp Renewal Form / Gr.rrduior.or--rfl& ecirefl o-pafl$ Glpnmo
qgft0$p'il ugai

nlg.fl[od"riluogaheei:oilunnin@
Academic Year
B) gSropu oeilo9luLnaingeir r-onerurn&46&g
Sl$grnpu.rneir ruprfu stuiu gofl$p gflufL-@
nain
Scholarshi Student ID
C) g$ropu.r sefu oflu:nnftrgou lonarrnBog rig
ruprlraiuir- Ggriq upsq manr lExam Register
Number)

1 EEmEtr outuffiffi 6u'u(Dri gqpetr grlgeoLourrn

goruflrqril/Institution Name & Address

@ftr.
1)Phone Number of the institution
2)Mobile Number of the person dea-ling with
Scholarship subject
oou.osl$lcoouL$$letrr-61 5rr6ur@ Ed groofl
e-mail id of the l::rstitution
2 lorr6ln6uF/m-nrmrmGuurri
Students Name
3 @emrir /Gender
ggainiGluain/geirpmir una5lrmLi/Male / Female
/Transgender
4 on$ oflornir /Community Details
Slrw$pzun (SC)
(a)uL-9u.reir
(b)upnaggu9erni (ST)
(c)dlSl$g16u t09$$l$g Lonp5iu.r urguoil Slco$pruf
Scheduled Caste Converted to Christianity
(scc)

en$ zi0rfla Gluui/Sub caste Name:

gx.4|.s..q!'|6,c. q[.f .u.F.?4&75-3.15,l0o cps..so/ l5. tO4/23 2oZ3

r 6rr, ,,.9.'E ,
 2

5 I) $lrrjpr Uooorfl lPermanent Address Il)pfionaflo goeeurfl /Iemporary Address

6 loffiarnffiSeffindtr
Student Aadhaar Number
7 ultr6!'dr U 5'I66IT

Student Phone Number

8 I.l)II6[TT6ll 66t @E5u (915 n.rrfl
Student e-mail ID
9 urutr-llrfl aSlet'r Gluu.ri/ Subject Name

10 uu9gtdr o6L-rir / Studying Year Bdt ( ) 6leriruqrir)

a)Second year b)Third year c)Fourth year

d)Fifth year e )Sixth year

i1 priq er oflureomg6u mn6u[roJr 6x(6utl5u GEtrp

pneh/Date in which the applicant joined the
class in current year
t2 un5rdTorrT (9F6n9uJ o6rno ofllgtsen@
Last year student attendance Percentage
Upropur erLollurairngoL pror Or-rrjrp groeur$gt
1?
Gpriqoroanqri urrrmmi ag$qeirrnnryn? (Yes/No)
6rGgg1n Gpriq ngpofl 6U5-O6l) eroflot: g4giaror
onroronir (u-fi$lroru arfluJl6srosu neuflsir Ln6$gtru&
enrt'rE $lroeuur$goirornrn ?
t4 l0n6drTrrlf oflGl6u9ougrildl uu9ouu arf (s0
ofl @$lu$eil pnrong uuSlouui
Hosteller (or) Day Schol ar
15 l)r-onornui ofl @$lu$6 prardl uu9euuoli noflo,
ofl@$luietr Gluun / Where the applicant is
residing in the Hostel nAme
z)S!frp gnin@ olt@$iufleir Geifp Snsit
Date on which the applicant joined the Hostel
Current year
3)a9@p odro5l $leoouigrd'r $leoeum$grshrnpr?
Where the hostel is attached to the
institution?

I
 3

alponumi an@$ oofldr eugir odn9lflEsurur$

psooeu[n6 gridorflrioriuiL-gn? If private Hostel
whether it is recogrr.ized by education
institution Head.
5)g{fiSofldiotuiL- poflu.rmi n9l@$ aofleb ( o-omq
LnpErrir o-ropofluoopqri;ono aiL-eounb
6r@66ldr6iu@dlp gt? lf rccogoized private Hostel
whether Pees collected for food &
Accommodation )

6)g4drdorflrioriuir prrflumi on@$ noflo,

@ooeLono e-56urol upglri e-ropoflL-ir
rupriratu@dlppn Recognized private Hostel
whether food & Accommodation free)
16 gr1e o$l@$]un? grir crofld.r, oflonraaeh grlaflBaqLiMhether the student is staying in the
Golt. Hostel. If so, indicate details there for.
1)€U6Slrnoflut peu$g6op o$l@$l
Adi- Dravidar Welfare Department Hostel
2)0fr urGL-mi po$g6utp on@gl
Backward Class Welfare Depa-rtment Hostel
3)r-6lo6rtri Opu@$piur-GL-mi ufrEri: dlEunstreoLou5lruni
pogglcop ofl@$l /Most Backward Class and
Minorities Welfare Department Hostel
4glpn ntlGl6lo6h gpiltLflr-qLb /Other hostels
please indicate
17 afl@$ldi om.rurrnflri'r Ouu.rri LofrEtt roo0u.rmjrurir /
Hostel warden Name and Signature

18 pL-riq ooua0u.rneringdr Gpriq 1glgu.tri ronpri loEEII)

ellgr--rh/Current Academic year exam close
month and year
19 aflaineuunirupnrni , r ri-r o-rurglfpruun?ggLir rrofkir, Oung$puneoerfieop g& Gleriruqri whether
the applicant of physically disabled Ifyes, tick (i ) the suitable.
(s{) umiroer6gropq /Low Vision
(eD erg Gsru$lefu g5opru5iT6n6rxi/DeaJ

6r) Glpng@rufleir @0,6$ rfrrmoriorir / Recovered from leprosy

(r0 ueorGpnu.rnoi.: un$lturoqi;prurioeir / Psychologically affected
(r-) rns. onri:orh oqrmgrlbE 6ILp$g16r,6dnuFffi6,mil
zpn9lquetr ori:gffitsg Glrdruarri/ Orthopedically
handicapped going to college with the help of an escort
(oEq) roo, ondroeh oorurgrfrg odrffiqL-rir @oocuon$p ofl@$uskir
6tuoriooir/Physically handicapped students
prirdlufl
staying in hostels attached to the Institution
(o) greonr errmi&dl gotrfluerrialgBonrn Clpriq uu9frdl
GluEuerriorh/Special coaching for mentaily retarded
person.
 4
r"0rr6dlr6!ri........... ...................un$Iil$rnnot lrab o*omgr$pelri cretrgdr
ronrrmoi osbgtrflqlrir 6l-*pp n9l@Fun6ir pnudl uuflsbdtpnri / ru$l$grnromrulnrmi rpoflqretr
srirgnflBg e$,gl Glerildlpmi / grrursn ornri&fl grop$porisg&onem Clpriq uuflfrdl OuEuelri crrirELir
oneirpofl ri;dkmGpen zrfl u enrtrE1ooir Strmerur6oiui@ orfl unriri;oturr gt.
Certified that the students ........defect is physically
cha-llenged and is studying in the institution as hosteller attached to the institution
coming to institution with the help of a gqve / receiving special training for mentally
retarded person. Due certificate re enclosed and verified.

20 r-0r6urrorflrtr oirir6} orumdig ofluryril /Student Bank Account Details

Lonrrnnrrfl eir ruri6l oromti1g crrrur'.
Student Bank Account Number
1 ermrdl GLuri/Bank Name

2. rurardl 6koen / Bank Branch

o MICR Code/MICR gfiu9@

4. IFSC Code/ IFSC gt'luS@

2l (gE6DpuJ ori:oiunotr@onflrt Lnnrrrnrdori uufl sngr ogriqaaflri:

$itryG.gt oda9l rpofl6Glpnroo $rruooflrtrd$
oflarirrunnltl$g orila9 rpofl$Glpncne Gufrperrn ? (gLi;
crofleir (g6np nrdr uueirpgLir oei:nfl lpoll$Gpnroo
$lrr$$irir 6$ 6lufrgt ooilai rpofl$GlpnroouSlrorm grgreri
oanr66kir $166u Gleg$$l, CleE$gld drgem peor:ru
Slrorrn6oriur Goeurr@6). Whether the applicant is in
receipt of more thal tw-o scholarship including this
one? If yes, he should return the scholarship to
Govt., which is less beneficia-1 to him as per hrs
choice and challan copy should be enclosed.
(ii)6legt$gt&drgerr antur Lo$Et pnoh
Challa-n Number and Date
22 prriq oa allunaforgrir ffi
o-pofl$Glgnroo $lrr$nnp po9n 6lprr oetn5l rpo9$Glpnooo
$hrrlreoflem 6!: uuei'r0u.o nflrrnrrnriLfl$grirennryn? ggLi:
gpor a9lolair. Whether the student has applied
erofldr
for any other scholarship scheme other than this
scheme? If, yes provide the details of the scheme.
 5

[email protected]
DE(CLIIRATION OF STUDENT
t) Sldoflainrumrlu$prir gdl[i0Ltutl@ohen gi6o6urpgt oflorriroqgri eflurcnroo Logglri)
E-sdnrouu:reurroo 5156r ' g,r$lu.rafl&6lGpetr. rntromril gqaflriioriuiL- GLofsnim aflorrrlrooir OetrrrTndlfl6i)
prugt rror sobrupilu:riuiL-nsir nro&g griuaflriiatu@rir ad:ofl e-pofl$Glgr66)5 (gr(86rl6opErir g4no
oflgk;grh enlp o$lu9tg1t 6OnO g{61fl&o $leoodlGpst'r 6r6uT tlrrTllrrl o-E$l g6lfl66lGpoi'r' I hereby
declare that all the details submitted application are correct and true. If any of the
details submitted is found to be incorrect later, then I hereby give my consent to
return the scholarship to ebed sanctioned to govemment in any means prescribed by
the government.
2) pL-tq osi:allu.rnrongdr GunoiuL- Gldrfl& ozuoll zpn$l$Glpnrne 6gi onfiitr6rurn'$$g1 6lpti
a$$w I Lo@o gre odrofl e-pafl$Glpnroo 5[r-riooflrt'r tgLir uu.retr6lup nnninourudl$$l6t0str,
S6trgl{ti@ Grofur--r-- $tL-.r-rireoflotrr S$ uuffiup uneuurn&eri Ggriq GluErir Gprio$lou unrrmn6s651
oll6riqrflroLougeirug g6ls uu.retrGuELb $I-r$$elr d[: sei:er9l rperllgiGtpneoeeoul Glu&gud;6l6n5r6l@
g6oprur6rr uurirpgtir $llunuoaflrt'r 6$ Gupnu@rir $l$lqpofleou g4nc6 eemr6615t p15tr9& Glogl$p
e-E$lunflri6lGpetr. In the event that 4 I had / have applied for Post-matric scholarship and
any other schemes of Central / State Go'tt. in current year / previous year arrd if
I am /was the student is selected for the award of scholarship in more than one
scheme then I hereby give my consent to return the scholarships under the schemes
to Government and retain one scholarship of higher benefit as per my choice.

Student Signature.

DECLARATION OF HEN) OF TIIE INSTITUTION

1)uneuoori odorfl rpofl$Glpneoo Glugr GunglLonrn arlgrno oflqg&on@ GluSEofuonmi
crrm anetrpafl&61Gprtr. Certifred that, the student has secured requisite percentage of
attendance for sanction of scholarship
2)ronrrnn&ori erftainrunnu$616i) qSlirSlrr oflorr'raeh ofEri eLorinr$$p goerunirernor
ggrirq Glorirppam g4gLiuroru9ob SlLiuneuurn6aqgBg Gunnuri GlLor-rfld; osirnil rgafl$Glpneoo
$hr$$lotr 6$ sofuo$l rpnfl$ 6lgnrns Gtrp p1g61 eunrir$pruri nrm oneirpofltidlGpsi'r. potpnem
a$lrrlrirarosir euriirg$pgr rJletrrnri eeuotflurluirneb ppGung griuoflBotu@t osi.:o$ ooti;o$
Glpnroo grlgzuoopu.lri qr66(g crrler$luigri Lonernn6orflrr-6lo6grt or@fil GloLitg gl[eti
Ceg$p q ErgludrflBdlGp6in. The details submitted by the student in
oeumtsdliir $@n8t+
his application are verified and post matric scholarship has been claimed based
on those verified details. If it is found that scholarship has been claimed by
institution by submitting incorrect data, scholarship obtained so will be retumed
to government account in the manner as prescribed by the government.
3) prtq soiroflunnirngeu Lnnsumn&ori Gunriui GlLoirflB oeilafl lpo9$Opnroe&iqLb
n9lninrrurnr9$gr GruE sriroli e-pofl$Glgncoo $hrmeoflet'r 6$ uuei'rGlup oflainrrnnfl$$lig$pnrir,
S$$hr$$tm d$ uuetrGlrp r-onrunnti;ori Gpriq GluELir Gprinlle Lonrrnn6ori ofl6tqrflroLou9lrtrug
et$lo uu.renGluErb $lrr-$$etr d$ esbaf) rper$l$Gtpncoseou Ou0gtritclan66n$l (55op6xn5ur
uu-rotrggLb $lur$$let'r d$ Glupriu@Lir $1$lqpa$leuru LonecnndarfLdlqppgt GUg6b Gtetugl grga&
oour66lob $16ffi& Glogr$p o E$luLaflri;6lGpeiir. If the student has applied for more than
one scheme including this scheme and if the student is selected for the award of
scholarship under more thal one scheme then as per the choice exercised by the
student, scholarship benelit under the schemes will be remitted to Government
account by recovering tJle student.

Place:
Principa-l Signature with Seal
Date:
 I

arflumitq uigu.rtil / CHECK LIST

@rorrur&ariuL_ Goningu ggzurumraraaflrt'r Sleorooqgtsg o$lGr e-eirnr

srr$$lsu i g& GleLiru:qri)

1 . u$lfrGlunirr sn5tTmro5h 2.onrdl oorrtsg u$pa gpsb u&o pozu

Mark Certilicate Bank Pass Book First Page Copy.

3.o6eoo6, onrirE grleru

a. pr6lppnreor Grri$p onccnnBst
Greraflonfleu aoirar5l flgloenri,raofleit
Attendance Original Certifi cate uuS1zuueut aouflsi.r ssUer9l d$.-
exri,rdsntrd enehEt ro@Errb seue6)
flEreuco$pnou ronecneu1566
eugrirsuurr- aer:srfl& rnailg.
5. onfEr$g9peonaflune @6uL51e&r Whether the student trelongs
gpO6nd6r Gpdlur €!6r'rLtuII6TI to the domicile state of
gqrror paer:. If physically Tamilnadu and studying in
disabled, enclose National ID other states? If yes, enclose
proof copy. Insitution's latest approval
copy and enclose Bonalide
Certilicate.

6.gfrrogur gJnrnr+rir earEti;g Gmfruir $lrrmeafleir 6$ oriro$l zpnfl$Opnroo

Glupp Gprioflrir (O6op6un6dr uuetrGlrELit $lrr$$lar t1j1 Gluprlur.-, oobai
o-pofl$Glpnroarou grlrarig $6nr9 GleE$$lup$anrm Glegl$g1& dr@ pad:.
If the student is in receipt of Scholarship under more than one
Scheme in the previous year then challan copy for the remittance of
scholarship received under the scheme where the benefit is less as per
the choice exercised by the student to the government.

pdlpopgki, ur0glrir ranrmrn6eriaqg&q ui@6

gflirq:-(1)praroeng oefuoll rpog$Glpnros o5lafurffiriu$$looour St$gl6Dgru.rnsi.r pnnrosh uuSlgrir

ueirsfl / erfug4rrflriO opriroriurr Slroermuer$l uurnri ggiluf@ (Login ID) grorir Sleorrrnu
uu:etrunige u$lGnL$prir Glerir$ oLoriur9&oriu@Li. gruo:nE uflu.r onru$$lob grraoeir uuigrit
urhofl / odrgrrfl g:ruuns prisnrgt o$lninontu$$lrorn Sleorrnu.r orLgflu5loir upGofpdr Glerirgdlei.
pniropq6Glorm p6uflpp tsg g{solrurrclr q$[Lir@ erain (Scholarship Student ID)
erpauoriru@Lir. gqpetr r9ei,r Lonzuir g6$l$irrroflrri LoSEt uprargguflrrri pru g4Eerrui LofrE[r
Glprn-riqsoru.r g]rop$grooaLrie eir urfl$g]rorru9ffu g4giruroruflei-r Lonrrnntiofalgrnru.r orirdl
oerur&dlo odmll lpofl$Glpr6o5 6xrJo.l eoerltiiotiu@Lir.

(2)unenrn&orie6h prarenrg Student id

g:euLir aoba9l rpofl$Gtpnsoo aflrunermriu$$lrtr
$lcoou5lrureurg{pfrGlscn crflu $lroeuouprn grser"rrfl greudr Sqfl$5 Glonthrnomir.
(prflBpmraeu lshan ushafl Lopgrb e ebgtyrrflsqgd;g Lor@tb).

Slcocraugen groorfl: htto: / / escholarship. tr-r ov-in / scholarship. h tml