INTEGRAL COACH FACTORY, CHENNAI – 600 038
APPLICATION FORM FOR WARDS OF ICF EMPLOYEES FOR APPLYING FOR SCHOLARSHIP FOR TECHNICAL EDUCATION FROM SBF
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1. Name of the employee :
2. Emp.No and T.No :
3. Designation :
4. Office/Shop :
5. Whether Class IV or III/SC/ST :
6. Present pay and scale :
7. a) No. of children :
b) Name of son/daughter/
dependent brother/dependent
sister in respect of whom
scholarship is applied for :
c) Whether father is alive or not
(in case of dependent sister/
dependent brother only) :
8. Name of the course of technical
education undertaken by the
student :
9. Duration of the course :
10.Name of the Institution in which
the student is studying and the
state where situated :
11. Is the Institution recognized by
the State Government of affiliated
to the University, if so, give name
of the State by which recognized
or affiliated :

12. Certificate as below to be
attached
a) Attested copy of the
Matriculation/High School
Higher Secondary certificate
and mark sheets of the
student :
b) Attested copy of the Inter-
Mediate certificate and
Mark sheet of the student :

c) Attested copy of B.A or B.Sc,
degree and mark sheet of
the student :

d) A certificate in form ‘A’
attached from the Head of
the Institution where the
student is studying :

13. In the student receiving any
stipend or monetary assistance
from any other source for the
course of study undertaken by
him or is he enjoying free
ship, if so give details :

14. Declaration by the employee :

I hereby declare that my son/daughter/dependent brother/dependent sister for whom this application is being submitted is not in receipt of any stipend or assistance from any other source for the course of study for which scholarship is now applied for the that the particulars as given above are correct. I also give an undertaking that in case any stipend or assistance is granted to him/her subsequent to the grant of scholarship now applied for this will be immediately brought to the notice of the Secretary/Staff benefit Fund. I also declare that my son/daughter/ dependent brother/dependent sister failed to pass any examination held at the institution where he/she is studying, I will immediately supply this information to the Secretary/SBF.

Date: Signature of the Employee

Countersigned by:

Date: Designation of the
Immediate superior:

Form-A

CERTIFICATE FROM THE PRINCIPAL OR HEAD OF THE INSTITUTION IN WHICH THE STUDENT IS STUDYING.

Certified that -------------------- son/daughter/dependent brother/dependent sister of Shri -------------------------------------- employed as ---------- in the Integral Coach Factory is a student of this Institution and is at present studying in the ------------ year of ----------- course. The duration of the course is --------- years. The academic session is from ------------ to ---------and the examinations are conducted by the -------------------. He/She is not enjoying free ship and is not receipt of any stipend or assistance from any other source for this course.

The particulars of the fees to be paid by the student are as under:

1. Date of joining the Institution :
2. Date from which fee paid :
3. Yearly amount of tuition fees :
4. Yearly laboratory fee if any :
5. Yearly fee for field training
and crafts :
6. Yearly examination fee if any :
7. Yearly cost of books :
8. Yearly cost of equipments is any :
9. Yearly compulsory expenditure
on technical membership :
10. Any other items of compulsory
expenditure payable to the institution
giving the details of the expenditure
and the yearly amount involved
excluded the charges for hostel and
messing :
11. Is any uniform compulsory for the
student, if so the yearly cost thereof:

It is also certified that the minimum educational qualification for admission to the course which the student is pursuing at this institution is ------------------------

Seal of the Signature of the
Institution: Head of the Institution