Merck India Charitable Trust Scholarship Programme

Scholarships for Academic Excellence

Application Form

Please read the following instructions in detail:

Kindly read and understand the instructions before filling up the application form
The form should be completed in capital letters
Applications are invited only from the passed students of Std. X, Secondary School Certificate (SSC)
Exams
Please attach 2 certified copies of your 10th Std. mark sheet and 2 passport size photographs along with the
application form
Application form must be signed by the applying student and the parent / guardian of the applying student
Information about the MICT Scholarship Programme is also available on our website www.merck.co.in
All application forms must reach our office within 10 days of the declaration of the SSC Exam results
Short-listed applicants will be informed within one month of the receipt of the application form
Applications not short-listed for the scholarship will not be informed & no separate communication will be
entertained

Completed application forms must be signed & returned by post, fax or email to:
Merck India Charitable Trust
Merck Limited, Shivsagar Estate A, Dr. Annie Besant Road, Opposite Lotus, Worli, Mumbai 400018
Tel: 6660 9000 / 9125 / 29 / 22 | Fax: 2495 0307 | Email: charitable.trust@merck.co.in
Personal Details
Name:

Mr. / Ms. ___________________________________________________________

(Please write in Block Letters)

Date of Birth:

(First Name)

____ / _____ / _____

(DD)

(MM)

(Middle Name)

(Last Name)

Place of Birth: ____________________________

(YY)

Parent / Guardian Name: ________________________ Service / Profession: _________________________

Present Address:

___________________________________________________________________
___________________________________________________________________
___________________________________________________________________

Permanent Address:

___________________________________________________________________
___________________________________________________________________
___________________________________________________________________

Contact Details:

Telephone Number (R): _________________ (Mobile): _____________________

E-mail ID: _________________________________________________________

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Merck India Charitable Trust Scholarship Programme

Scholarships for Academic Excellence
Application Form

Prior Educational Details

Examination
Passed

Name & Address of the School /

Division Board / University

Month and
Year of
Passing

Marks Obtained
/ Out Of Total
Marks

Percentage
of Marks
(%)

CLASS X
CLASS IX
CLASS VIII

Please mention your highest passed qualification / additional qualification (if any).
_________________________________________________________________________________________
Specify any academic / merit achievements or awards that you have received in the past
_________________________________________________________________________________________
Specify the educational course that you would like to pursue henceforth.
_________________________________________________________________________________________
Mention your reasons for choosing the above field of study and how do you think it will benefit you?
_________________________________________________________________________________________
_________________________________________________________________________________________
Which are the educational institution(s) you wish to apply?
_________________________________________________________________________________________
_________________________________________________________________________________________
Write in brief about your extra-curricular activities & interests.
_________________________________________________________________________________________
_________________________________________________________________________________________

Financial Details

Total number of earning members in your family: _______________

Total Family Income (in Rs.):

Below 5000 p.m.

5000 - 10000 p.m.

10000 - 15000 p.m.

Above 15000 p.m.

Please give details of your current sources of financial support.

_____________________________________________________________________________________
Please state your reason for seeking extra financial aid.
_____________________________________________________________________________________

Declaration by the Applicant and Parent / Guardian

I declare that the information given by me in this application for obtaining scholarship is true to the best of my knowledge and
that I have not withheld any relevant particulars. I have disclosed all the information correctly as required to be given in this
application. If any information provided is wrong or misleading, the scholarship is understood as seized immediately.
Signature of Applicant ______________________________

Signature of Parent / Guardian ___________________________

Date

Date

______________________________

___________________________

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