(Regd. No. 11/2016) No. 64, Sree Thiruvenkata Nagar, Maniyakarampalayam Road Ganapathy, Coimbatore, Tamil Nadu 641 006 APPLICATION FORM FOR EDUCATIONAL AID ±ÉÊPÀëtÂPÀ ÉgÀ«UÉ Cfð Put a mark or wherever required (or) strike out if not required ÉÃPÁVzÀÝPÉÌ ( ) aºéß, ÉÃqÀªÁzÀPÉÌ (x) Application No. Cfð 1. of the applicant : CfðzÁgÀgÀ 2. Date of Birth : d Àä ÁAPÀ 3. School/College : ÀÆÌ ï/ PÁ ÉÃdÄ Passport size photo Á ï ÉÆÃmïð ÉÊeï sáªà avàæ 4. Class/Course : vàgàuàw/péæã ïð 5. Gender : Male / Female AUÀ ÀÄgÀÄ À / ªÀÄ»¼É 6. Nationality : Indian gá ÖçÃAiÀÄvÉ ságàwãaiàä 7. Present Address : Àæ ÀÄÛvÀ «¼Á À 8. Permanent Address : ±Á±ÀévÀ «¼Á À 9. Contact No. : ÀA ÀPÀð ÀA. 10. Family Members Details : PÀÄlÄA ÀzÀ ÀågÀ ªÀiÁ»w Relationship ÀA AzsÀ Age ªÀAiÀÄ ÀÄì Education ²PÀët Occupation GzÉÆåÃUÀ Page 1
11. Is there any Physically Challenged member in your family? If yes, specify ## PÀÄlÄA zà è AiÀiÁjUÁzÀgÀÄ zéê»pà zë ð å«zéaiéäã? EzÀÝgÉ «ªÀj¹. 12. Is anyone suffering / suffered from any major illness? If yes, specify (e.g. Heart, Kidney, Liver, Brain etc.): AiÀiÁjUÁzÀgÀÄ ºÀÈzÀAiÀÄ, ªÉÄzÀļÀÄ, PÀgÀļÀÄ ªÀÄÄAvÁzÀ zéæqàø PÁ Ä ÉUÀ¼À ÀÄß C ÀÄ sૹzáýgá? EzÀÝgÉ «ªÀj¹. 13. Source of income : DzÁAiÀÄzÀ ªÀÄÆ UÀ¼ÀÄ Age ªÀAiÀÄ ÀÄì Relationship ÀA AzsÀ Monthly Income wauà¼à DzÁAiÀÄ Occupation / Place of working GzÉÆåÃUÀ/GzÉÆåÃUÀzÀ «¼Á À 14. Total income per month/ªéævàû DzÁAiÀÄ Àæw wauà¼àä : /- 15. Major financial commitments, if any please specify (e.g.loans, Educational fee, Insurance etc.) : ºÀtPÁ ÀÄ zàývéuà¼àä EzÀÝgÉ «ªÀj¹. GzÁ: Á UÀ¼ÀÄ, ±ÉÊPÀëtÂPÀ ±ÀÄ Ì, «ªÉÄ, EvÁå. 16. Details of Assets / D¹ÛUÀ¼À «ªÀgÀuÉ House: ( ) Rented ( ) Owned ( ) Leased ªÀÄ É ÁrUÉ ÀéAvÀ UÀÄwÛUÉ Vehicles ( ) Two Wheeler ( ) Bicycle ( ) Others ªÁºÀ ÀUÀ¼ÀÄ ézàpàæ ªÁºÀ À ÉÊPÀ ï EvÀgÉ Home Appliances ( ) TV / DVD Player ( ) Washing Machine ( ) Refrigerator ªÀÄ É G ÀPÀgÀtUÀ¼ÀÄ n«/r.«.r. ÉèÃAiÀÄgï ªÁ AUï «ÄµÀ ï gé üædgéãlgï Page 2
17. Previous Sponsorship : Yes / No»A À ÁæAiÉÆÃdPÀvÀé ºËzÀÄ / E è and address of the Organization / Trust : ÀA ÉÜAiÀÄ ªÀÄvÀÄÛ «¼Á À Present status Àæ ÀÄÛvÀ ¹Üw ( ) Still Active / ÀQæAiÀÄ ( ) Completed / ÀÆtðUÉÆArzÉ ( ) Rejected / wgà ÀÌj¹zÉ If rejected, please specify the reason / wgà ÀÌj¹zÀÝgÉ,. PÁgÀtªÀ ÀÄß «ªÀj¹ : 18. References/ G ÉèÃRUÀ¼ÀÄ : School or College and Address: ±Á Á PÁ ÉÃf À ªÀÄvÀÄÛ «¼Á À 1 2 Designation ºÀÄzÉÝ Principal / Vice Principal ÁæA±ÀÄ Á gàä/g À ÁæA±ÀÄ Á gàä Class Teacher / HOD PÁè ï nãzàgï/ºézïmr Signature À» Contact No. ÀA ÀPÀð General Reference: ÁªÀiÁ Àå G ÉèÃRUÀ¼ÀÄ: Designation ºÀÄzÉÝ Signature À» Contact No. ÀA ÀPÀð 1 Declaration / WÉÆõÀuÉ I / We hereby declare that all the information furnished above is / are true to the best of my / our knowledge. If any information is found incorrect, my / our application for Educational Aid from Punyah Foundation can be rejected. Á ÀÄ/ ÁªÀÅ E èazà ªÉÄÃ É PÉÆlÖ J Áè ªÀiÁ»w ÀªÀÄUÉ w½ gàäªàavé ÀjAiÀiÁVzÉ JAzÀÄ WÉÆà ÀÄvÉÛêÉ. ªÀiÁ»wAiÀÄÄ và ÀÄà PÀAqÀÄ AzÀ è, À Àß ±ÉÊPÀëtÂPÀ ÉgÀ«À CfðAiÀÄ ÀÄß wgà ÀÌj À ºÀÄzÀÄ. Student Signature «záåyð À» Parent Signature ÉÆõÀPÀgÀ À» Place : ÀܼÀ Date : ÁAPÀ Page 3
Note: 1. In the case of minor applicant, the parent or guardian who signs the application form on behalf of the minorwill be held responsible, if any of the information given above is found false upon verification. apàì CfðzÁgÀgÀ ÀAzÀ sàðzà è, AiÀiÁªÀÅzÉà ªÉÄÃ É PÉÆlÖ ªÀiÁ»wAiÀÄÄ và ÁàVzÀÝgÉ, apàì CfðzÁgÀgÀ ÀgÀªÁV À» ºÁQzÀ ÉÆõÀPÀ/gÀPÀëPÀgÀÄ dªá ÁÝgÀgÁVgÀÄvÁÛgÉ. 2. Punyah Foundation reserves all rights to accept or reject the application without assigning any reason. ÀÄtå sëaqéã±à ï CfðAiÀÄ ÀÄß AiÀiÁªÀÅzÉà PÁgÀtªÀ ÀÄß G ÉèÃT¹zÉ, ¹éÃPÀj ÀĪÀ/wgÀ ÀÌj ÀĪÀ ºÀPÀÄÌ ºÉÆA gàävàûzé. 3. Documents once submitted will become property of Punyah Foundation and will not be returned. À è À ÁVzÀÝ zár ÉUÀ¼ÀÄ ÀÄtå sëaqéã±à ï ÀévÁÛVgÀÄvÀÛzÉ. ªÀÄvÀÄÛ AiÀiÁªÀÅzÉà PÁgÀtPÉÌ»A gàäv ÀĪÀÅ è. 4. All questions must be filled. Incomplete application form will be rejected. J è Àæ±ÉßUÀ½UÉ ÀjAiÀiÁzÀ GvÀÛgÀªÀ ÀÄß Ãr. C ÀÆtð CfðUÀ¼À ÀÄß ¹éÃPÀj ÀĪÀÅ è. 5. Photocopy of following documents should be submitted along with the completed application form. PɼÀPÀAqÀ zár ÉUÀ¼À eégápïì ªÀÄvÀÄÛ CfðAiÀÄ ÀÄß À è À ÉÃPÀÄ. a. Proof of Address and Photo ID of applicant / «¼Á ÀzÀ ÀÄgÁªÉ ªÀÄvÀÄÛ CfðzÁgÀgÀ sáªàavàæ UÀÄgÀÄvÀÄ. b. Proof of Age of applicant / CfðzÁgÀgÀ ªÀAiÀĹì À ÀÄgÁªÉ. c. Family photo, if available / PÀÄlÄA zà sáªàavàæ ( EzÀÝgÉ ). d. Recent marks or grades report issued by the institution / EwÛÃa À CAPÀ ªÀÄvÀÄÛ ±ÉæÃtÂAiÀÄ ÀÄß PÉÆlÖ ÀA ÉÜ. e. Current academic year fees details / Àæ ÀÄÛvÀ ±ÉÊPÀëtÂPÀ ªÀµÀðzÀ ±ÀÄ ÌzÀ ªÀiÁ»w. f. Income proof of family / PÀÄlÄA zà DzÁAiÀÄzÀ ÀÄgÁªÉ. g. Medical related documents/ ªÉÊzÀåQÃAiÀÄ zár ÉUÀ¼ÀÄ. h. Supporting documents for previous sponsorship, if any /»A À ÁæAiÉÆÃdPÀvÀéªÀ ÀÄß ÉA ÀĪÀ zár ÉUÀ¼ÀÄ ## Attach separate sheet, if necessary. # ÉÃgÉ PÁUÀzÀªÀ ÀÄß ÉÃPÁzÀgÉ eéæãr¹. Original documents must be submitted for verification # ªÀÄÆ zár ÉUÀ¼À ÀÄß Àj²Ã ÉUÁV À è À ÉÃPÀÄ. Page 4
(For Punyah Foundation use only) ( ÀÄtå sëaqéã±à ï ¼ÀPÉUÁV ªÀiÁvÀæ) Application Status / CfðAiÀÄ ¹Üw: ( ) Accepted ¹éÃPÀj¹zÉ ( ) Rejected wgà ÀÌj¹zÉ ( ) Pending ÁQ G½ zé If rejected or pending, please specify the reason: wgà ÀÌj¹zÀÝgÉ / ÁQ G½ zàýgé, PÁgÀtªÀ ÀÄß «ªÀj¹. Verification done on Àj²Ã É ªÀiÁrzÀ ÁAPÀ Verification done by Àj²Ã É ªÀiÁrzÀªÀgÀÄ : : Selection Committee Trustee President Secretary DAiÉÄÌ À«Äw læ¹öã CzsÀåPÀëgÀÄ PÁAiÀÄðzÀ²ð Page 5