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Organisation : Goa Directorate of Tribal Welfare
Scholarship Name : Pre Metric Scholarship Scheme For Scheduled Tribe Students
Applicable State/UT : Goa
Website :
Application Form :

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Pre Metric Scholarship:

Application for Pre Metric Scholarship Scheme for Scheduled Tribe Students

Related : Goa Tribal Welfare Post Matric Scholarship :

Application Format :
Application for Pre Metric Scholarship Scheme for Scheduled Tribe Students admitted to Std_________________ for the Academic Year______________

Fresh ________________ Renewal_________________

For Official Use Of Tribal Welfare Department:
Std./ Class :
Marksheet Grade :
Income Rs. :
Percentage :
S.T. Cert./ Community :
Stipend Rs. :
Aadhar Card No. :
Meritorious Rs. :
Status of Application :
Verifying Official :

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 ________________
Assembly Constituency ___________________________
State : GOA
Pin Code:_________________________
Telephone /Mobile No.___________________
E-mail I.D._______________

3. Religion: Hindu / Christian / Others______________________
4.Scheduled Tribe Community: Gawda / Kunbi / Velip / Others _____________________
5. Whether Male or Female: Male: ___________ Female: ___________ Other: ________
6. ST Certificate No: ___________________Date:____________
7. Aadhar Card No:___________________

8. Performance in the qualifying exam (Previous year Exam) for Merit Scholarship:
Examination Passed for Std.
Name of School & Address Promoted to Std.
Month/Year of Passing
Percentage obtained Class/Grade obtained

9. Details of Class/Std. of admission taken in the current Academic Year_____________
( i ) Name of Class/Std.:_________________
( ii ) Duration of Class/Std.: __________________
(iii) Academic Year : ____________________
(iv)Duration of Academic Year: ______________ (From Month __________To Month __________) ___________________

10. Details of previous school attended incase student has presently taken admission in new school.
(i) Name of School: _____________________
(ii) Address of School____________________

12. Annual Income of Parents/Guardian of the Student: Rs.__________________ If Income Certificate is of guardian state the guardian’s name and relation with student (Please enclose copy)

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: ________________________ (In Words) ________________________
(v) MICR Code of the Bank: _______________________
(vi) IFSC code of the Bank branch:_____________________

15. Document to be enclosed compulsorily with the Application:
I. Passport Size Photograph.
II. Attested copies Marksheet / 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 copy of Bank Pass Book.
VI. 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 Pre- 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 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]:
17. Details of School, including residential ones:
(i) Name of School, where admitted with address:
Name: ________________________________
Locality: ______________________________
Waddo/Street: _________________________
City/Town/Village : _____________________
Taluka : ______________________________
District: _________________________
State : _______________________________
Pin Code: _________________________
Telephone No.: ___________________________
Fax : __________________________
E-mail I.D.:____________________________
Website : _____________________________

18. Verification / Information strictly to be furnished only by the Head of School: (All the fields are compulsory)
1. It is certified that the information filled in the above mentioned columns by Mast./ Kumari ________________________________ s/o/ d/o/ Shri. _______________________________ who is admitted in Std._______________________________ for the academic year ______________ in this school is correct as fresh / renewal.
2. This is Govt. School /Aided by Govt. / This is Private School, run without the aid of Govt.
3. This institution is affiliated to _________________ Board and is recognized by the Government of India / Goa.
4. It is certified that the above mentioned student has passed Std. ____________ examination for the academic year ____________ and has obtained __________% and __________ grade.
5. 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.

Signature of the Head of the School/ with Official Seal

Place :

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