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Organisation : Goa Directorate of Tribal Welfare
Scholarship Name : Post Matric/Gagan Bharari Scheme/Merit Base Scholarship
Applicable State/UT : Goa
Website :
Application Form :

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Post Matric Scholarship :

Application for the “Post Matric Scolarship Scheme and Gagan Bharari Scheme/Merit Base Scholarship”

Related : Goa Central Sector Scholarship Scheme 2017 :

Application Format :
Scholarship for Scheduled Tribe Students for the Academic Year______________

For Official Use of Tribal Welfare Department :
Income Rs. :
Std/Class :
Percentage :
S.T. Community :
Maintenance :
Merit Based Award :
Group :
Fees :
Gagan Bharari :
Day Scholar/Hosteller :
Amount :
Aadhar Card No :

Verifying Official:___________

Fresh ________________

Part –A [To be filled up by Applicant]:
1. Full Name: (in block Letter)
First Name: ______________________
Middle Name: _________________
Surname: ______________________

2. Address for Correspondence:
House No.:____________
Waddo/Street: ____________________
City/Town/Village: ______________________
Name of Village Panchayat/Municipality:_________________
Taluka ___________ District:_______________
Assembly Constituency _____________________
State : GOA Pin Code:_____________________
Telephone /Mobile No.____________________
E-mail ID_________________

3. Religion: Hindu/Christian /Others
4. Scheduled Tribe Community: Gawda/Kunbi/ Velip/others
5. ST Certificate No: __________ Date______________
6. Aadhar Card No:___________

7. Details of educational qualifications from matriculation onwards:
(Please enclose attested copies of Certificates)
Examination Passed :
Name of School/College/Institute University/Board/Institute/ Council of Examination:
Year of Passing:
Percentage Marks Division /Class/Grade:

8. Details of Course for which scholarship is being sought:
( i ) Name of Class/Course:________________
( ii ) Duration of Class/Course: ______________
(iii) Academic Year : ____________________
(iv) Class/Course last attended/academic year : _________
(v) Total Marks Obtained and percentage in last examination: ___________

9. Details of School/College/institute, including residential ones:
(i) Name of School/ College /Institute where Admitted: __________
(ii) Address of School/ College /Institute: _________

10. Total Annual Course fees: Rs. ______________

11. Day Scholar /Hosteller/Distance Education: __________If Hosteller then please specify
(i) Whether staying in the hostel run by the school/collage/institute: YES/NO
(ii) If no and staying as an outstation student as paying guest or in rented accommodation in towns/cities which are not the places their parents resides, then the postal complete address of the landlord:

Name of landlord ___________________
Rent per Month _______________________
Full Postal Address _______________________
Telephone /Mobile of landlord ________________

12. Annual Income of Parents/Guardian of the Student: Rs.________

13. Details of Bank Account of Student:
(i) Name of the Account Holder :________
(ii) Name of the Bank: ________________________
(iii) Bank Branch ( Full Address): ___________________
(iv) Bank Account Number: ________________________
(v) MICR Code of the Bank:
(vI) IFSC Code: _________________

14. Whether applicant was in receipt of scholarship under this scheme or any other scheme in the previous year, if yes, indicate name of the scholarship scheme, course and institute:

15. Document enclosed with the Application:
I. Passport Size Photograph.
II. Attested copies of Mark sheet/Passing Certificate.
III. Attested copy of Income Certificate issued by competent authority.
IV. Attested copy of Scheduled Tribe Certificate issued by competent authority.
V. Attested copies of Fees payment receipts.
VI. Attested copy of Bank Pass Book.
VII. Attested copy of Aadhar Card.

16. Declaration:
(i) I hereby declare that the information given above is correct.
(ii) I am not availing any other scholarship for this purpose from any other source.
(iii) I shall abide by the terms and conditions of sanction of the Post- Matric Scholarship.

(iv) I undertake that if, at any stage, it is found to the satisfaction of the sanctioning authority that the information given by me is false or if I violate the terms and conditions of the scholarship, the scholarship sanctioned to me, may be cancelled and the entire amount of scholarship will be refunded by me or recovered from me, apart from me, apart from such penal action as warranted by law.

Date: ______________
Place: ______________

Signature of the student : ______________________
Signature of the Parent/ Guardian : ______________________

Part –B [To be filled up by the Head of the School/ College /Institute]:
17. Details of School / College /Institute, including residential ones:
(i) Name of School / College /Institute, where admitted with address:
Name: _________________________
Locality: ______________________
Mohalla/Street: _____________________________
City/Town/Village : _____________________
Taluka : ______________________________
District: ______________________________
State : _______________________________
Pin Code: _____________________________
Telephone : ___________________________
Fax : _________________________________
E-mail :________________________
Website : _____________________

18. Verification / Information/strictly to be furnished only by the Head of School /College/ Institute compulsorily:
1. It is certified that the information filled in the above mentioned columns by Shri/ Kumari _______________ s/o/ d/o/ Shri. ___________________ who is admitted in ________________ Course for the academic year ______________ in this school is correct .
2. He/she is a Hosteller/ Day scholar / Distance Education of the School/ College/ Institute. or He/ she is staying as paying guest /in a rented accommodation at the address given at para 11 as per office records.
3. He /she is a fresher admitted in the school for academic year _________________. or He/ she has been promoted from class _____________to ____________ in the academic year _________
4. Name of the course in which the applicant is studying in this institution.
5. This institution is affiliated to _________________ University / Board and is recognized by the Government of India / Goa.
6. Compulsory fees and other incidental charges to be paid by the applicant to the institution for the current academic year from ________ to __________ as per details given below

Particulars of all non- refundable compulsory fees payable by the applicant :
1. Tuition Fees
2. Examination Fees
3. Games
4. Medical Examination Fees
5. Library fees
6. Identity Card Fees
7. Practical Fees
8. Enrolment Fees
9. Laboratory Fees
10. Any other fees compulsory payable (to be mentioned item wise)

Total Annual course fee.: Rs. ___________________

: Enclosed fee receipts issued by the institution /college / University should tally with fees Structure approved by the Government for concerned stream.

7. If the applicant is residing in Hostel, indicate if He/She is entitled for free boarding and lodging: __________________________________

8. In case the applicant leaves the institution or otherwise discontinues the studies or accepts any other scholarship/stipend, the fact will be immediately reported to the authority so that payment of scholarship to the applicant will also be discontinued. The undisbursed amount lying with the institution on account of maintenance charges, fees etc. will also be refunded to the Government account.

Place: ___________________
Date: __________________
Seal of Institution : _______________
Signature of the Head of the School/ College/Institute with Official Seal : _____

Part –C :
“Gagan Bharari Scheme/ Merit Base Schlorship”

[To be filled up by applicant / Student]

19. I am studying my post- Matric education and I am eligible & applied for the Post Matric Schlorship for Tribal Student for the year __________________. I am therefore eligible for the Gagan Bharari Scheme and Merit Base Scholarship of the Tribal Welfare Department of Government of Goa.

1. Name of the Qulifying exam passed with Board/University, Month and Year of passing exam (Previous Acadimic Year)
2. Percentage of marks obtained
3. Name of the Course / Standard
4. Course Duration
5. Government aided Course/ Self- Financed Course.
6. Course affiliated to Board/ University
7. Non – Refundable Course fee for the entire year

Date: ______________
Place: ______________
Signature of the student _______________
Signature of the Parent/ Guardian ____________

Declaration of the Head of the Institution:
I, Shri. ________________________ Principal/ Head of the institution ________________ (name & address of institution)do hereby confirm and certify that the above details given by the student is correct in all respect as per the record maintained by the institution and as such above named is eligible for the Gagan Bharari / Merit Base Award Scholarship of the Tribal Welfare Department.

Date: ______________
Place: ______________

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