APPLICATION FORM FOR HGF SCHOLARSHIP

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Students in 09 to 12 standard, scoring minimum 60%, are only eligible.
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Application must reach to JCI India National Headquarter on or before 30 June 2019
One LOM can send max 10 genuine students applications

Name of Sponsoring LOM__________________________________________________, Zone_____________

Name of the student in full____________________________________________________________________

First Name Middle Name Surname
Date of Birth ____________________ Contact No: ________________________________________________
Class in which studying now _________________________ (Students of 09th to 12th are only eligible)
Percentage of Marks secured in the last annual examination: ________ % (60% and above only eligible)
Residential Address of the student:_____________________________________________________________
_________________________________________________________________________________________
Pin code_______________ Email id (if any)______________________________________________________

Bank account detail of THE STUDENT (compulsory): (Please enclose cross cheque leaf) Recommendations
___________ if any
from JFP & above donor
Name in Account: ______________________________________________
Name of Bank:_____________________________________________________ Name of the JFP/JFF/JFS:_

Account number:___________________________________________________
IFSC Code of Bank:__________________________________________________ LOM
JFP/JFF/JFS____________
Bank Branch Name:________________________________________________
___________________________
___________________________
Name of Father/Guardian __________________________________________ __

Occupation of Father/Guardian______________________________________________
Annual Income of the Father/Guardian. Rs. __________________________________
I hereby declare to the best of my ability that the above information is true and correct

_____________________________ _____________________________
Signature of Father/Guardian Signature of the Student

CERTIFICATE FROM SCHOOL/COLLEGE/INSTITUTION

I____________________________________________Principal/Headmaster of__________________________

_____________________________________________________________________School/College, here by certify

that the applicant is from an economically weaker family. His/Her conduct and character is good.

Date ________________ Name of the Head Master/Principal with seal/stamp

IMPORTANT NOTE TO SPONSORING LOM

The following documents should be enclosed with the application form: (Compulsory)
(1).Mark sheet of latest/last Annual Examination certificate by School, (2).Recommendation letter of LOM
President (3) Recommendations from Donor(JFP & above) if any, to be filled as given in the box above.
For Income proof, please ensure the above certification from the school, in the box, is filled up and certified

Name and Signature of LOM PRESIDENT

Please note, If the student does not have account number, then cheque will be issued in students name and In such
case, if the cheque is not deposited in the bank by the scholarship receiver, within validity period then revalidation of
such cheques will not be allowed by JCI India.