1

2

3 Roll No.

4

5 Father's Name

6

7

8 Converted to :

9 Chirisrian : ( )

10 Muslim : ( )

11 State Govt ( ) Central Govt ( ) State Govt Employee deduct DAIncome Limit : below 2,00,000/-

12 10th Reg. No.

13 (2)

14

1516 MICR Code IFSC No. Bank Name with Address

17

Room No.

Block No.

Hostel Name

18Permanent Address with Pincode

Door No. and Street Name District and Pincode

19 Date of Admission:

20

Date :

Check List for BC/MBC Scholarship for the year 2019-20 - UG FRESHTick in the appropriate one clearly

Branch and Course

Year of study Regular Programme ( )

Name of the Student

5A) Mother's Name

Gender Male ( ) Female ( ) Transgender ( )

Date of Birth

Religion

Community (as per Community Certificate) BC( ) BCM( ) MBC( ) DNC( )

Caste

(1) Income (as per Income certificate) Income Limit : below 2,00,000/-(2) Occupation:

+2 Reg. No.

Mobile No.(for contact) Student(1) Father (2) (1)

Different Abled Person Eye ( ) Hear ( ) Ortho ( )

Email Address :Saving Bank Account No. of the student

Address for Correspondence (Present Address) with PincodeDay Scholar Anna University Hostler ( ) Free ( ) Private ( )

Address 1

Address 2

SIGNATURE OF THE STUDENT WITH DATE

SIGNATURE OF THE CLASS ADVISOR

City and Pincode

Village and Post

Date of Joining (Hostel) :

Enclosures Last Date for submission : 16.09.2019 IMPORTANT : All Xerox copies should be Sign, Date, Name, Roll No., Branch under the page bottom.(1) Community Certificate Xerox copy with self attested as per above(2) Income Certificate Original (3) Mark sheet of 10th, +2 Xerox copy with self attested as per above(4) SB Bank pass book front page Xerox copy with self attested as per above(5) Adhaar No. and xerox copy