INDIAN INSTITUTE OF TECHNOLOGY, KANPUR

All the fields MUST be filled. Write N/A if Not Applicable.

Incomplete document will not be accepted.

1. Name of Scholarship M MCM

2. Name of the student RANDHIR KUMAR

3. Full postal address B326/ Hall 10, IIT KANPUR, KANPUR, UP-208016
4. Home phone no.

08604577676

5. Student Mobile no.- 07753886658

6. IIT Kanpur Roll No. 13553
(to be filled at the time of registration)
7. Name of the Department/ Program - ME/B.Tech
8. Category (GN, OBC, SC, ST, PH) OBC
9. Parental details:
a. Name of the father/ guardian PANDHARI RAM
b. Reasons for being under Guardianship, if other than fatherc. Fathers/ guardians occupation AGRICULTURE
d. Designation
e. Gross (pre-tax) annual income 30,000/f. Name of the mother KUSUM
g. Mothers occupation HOUSE WIFE
h. Designation
i. Gross (pre-tax) annual income N/A
10. Do you hold any scholarship from any other source at present (Yes/No) NO
Students signature

Fathers/Guardians signature

Mothers signature

11. In case your answer to line 9 is Yes please provide details of the scholarship
Name of the scholarship

Value of the
scholarship (In
Rs.)

Duration of the scholarship (From which date to which

date)
Example January, 2011 TO December, 2014

12. Declarations: (Please sign Declaration A if you have answered Yes in line 9 OR
sign Declaration B if you have answered No in line 9. Also sign Declaration C)
A. I hereby declare that I have provided accurate information about the scholarship(s)
I hold at present in Line 10.
Signature of the student
B. I hereby declare that at present I do not receive any form of scholarship from any
government or non-government source.
Signature of the student
C. I acknowledge that I have been informed that at IIT-Kanpur, no student can
receive two scholarships simultaneously.
Signature of the student
UNDERTAKING
I hereby undertake and certify that the information provided in this form is correct and
true to the best of my knowledge and belief and nothing material has been concealed.
I understand that in the event of any information being found false, misleading or
incorrect, or ineligibility to receive the Merit-cum-Means Scholarship being detected
during or after completion of my programme at IIT Kanpur, or any of the personal
information furnished in support thereof is found incorrect, neither I nor my
parents/guardian shall have any objection whatsoever against the action taken by the
Institute in the matter, in accordance with provisions 9.3 and 12.2 of the Ordinance of
IIT-Kanpur.
I further undertake that during the course of availing the Scholarship, whenever there
shall be any change in the income of my parents/guardian, I shall keep the Institute
authorities informed and shall abide by its further decision on my eligibility to receive
the Scholarship.
Students signature

Fathers/Guardians signature

Mothers signature