2016Please place pre-printed labelhere. If no labelis available,please complete the following information in CAPITALS:

Dakshana RolINo: g ri611+a 72JNV RollNo: + 15

Last Name (Surname):

First Name: v .[Middle/Other Name(s)

Gender (M/F)

d'

The Dakshana FoundationApplication to Become a Dakshana Scholar

Dakshana Scholars are brilliant, but impoverished students who aspire to attend The Indian Institute ofTechnology flIT), but cannot aff ord to be coached professionally by a world-class lIT JEE coaching institute.The Dakshana Foundation provides comprehensive scholarships to gifted/impoverished adolescents whomeet our criteria. These scholarships include 100% of coaching fees and books. In order to be eligible toapply for becoming a Dakshana Scholar, you must be invited to appear for and qualify in the NavodayaDakshana Selection TestjNDSTI. The decision of Dakshana in this regard is final

Ihereby do attest that allof the information submitted in this application is correct and authentic and that Imeet allot the criteria mentioned to apply for being named a Dakshana Scholar:

.o4,...C>.1.;..2,01..6.Date

o 1. o) . Z.oooBirth DateIday/month/yearn

StudMnature

Parent/Guardian Signature Date

Page 1of 4

PLEASE DO NOT LEAVE ANY BLANK COLUMNSIN THE QUESTIONS BELOW; PUT "Nll!' or "0" WHEREIT IS RELEVANT.

.S&f...yJ:U.i:.IW E:£T....SiK/ G H 'Father/Guardian's Full Name

.£4.R.M..E.R.Occupation

~s . ........t.2,..0..a.Q.........TypicaIMonthly Income

.B..:..A. ..H.£N..DIFather's Education Levelje.g. B.A, 12th Pass, toth Pass, Illiterate etc.I

Languagejslyour father can read and write

If your father is a farmer, how much land is owned (4..b:gila. hectaresl

Sn.L:......BA.ALIA......0.E V£ ...........HP.Q.S..E.UJ...£.e....Mother's FulIName Occupation

Rs.. . ....Q.Q .Q.. .. .. .. ..TypicaIMonthly Income

.I..l#.h..h:ss . .. .. . .Mother's Education Levelje.g. B.A, 12th Pass, 10th Pass, Illiterate etc.)

..H.I..N..n.Languagejslyour mother can read and write

Occupation-;. .. .....1...(2.0...0.. .. .........TypicaIMonthly Income

Ks

TotaIApproximate Value ofAll Household AssetsIExcept Household Cash Savingsl

~; I lbQQQTotalTypicaIMonthlyHousehold Income

~;. 2.0QQTotal Household

Cash Savingsd'

QH.he.£.. ..b.£x..&#.. 03Number ofbedrooms

Is your parents' homeowned or rented?

Approximate area ofParents' Home jsq. Ft.)

R Ba n n qn n asaHI

Monthly rent...J.:..N....V.:...............

Current/Last School

.aHA.R.Monthly schoolfeesSchoolState

Do you live in a ruralarea; IY/NI Do you live in an urban areal

Do you belong to aScheduled Caste?

Do you belong toa Scheduled Tribe;

Do you belong to Other Are you disabled orBackward Classes -- OBC? physically handicapped?

If yes, please specify the medicaldisability and provide proof of the same with this application

Please answer the following with a Yes or No. Does your family have?

Cable TV? Scooter(s)/Motorcyclejs) Home Phone Carjsl

.N.o.a Fridge

..N.o..a Computer

--b4Zil8#...,''.Bank Account

..)kh....Mobile Phone

Page 2 of 4

Please write essay (in English or Hindi) between 300 - 500 words which begins with

I'd like to become a Dakshana Scholar and hopefully attend lIT because

#"

<.'y«".*t

Page 5 of 6

"«J ' '

.I,h«£ .3 .A««. .8.c«n .4'''

K.s .NANA

IYou can use this form or a separate piece of paper. Please submit the essay in your ownhandwritingl

Page 6 of 6

Qualifying Board Exam for 10th Standard jcircle appropriatelyj: CBSE/ICSE/State Board

Standard ScienceGrade

MathsGrade Rank in School

9th Q.0..lq ' -lS ..... ..ilq.. ...... .....JA...... .... ................ out of .............................. students

10th Z.e.IS.. ..ib ........iA............. .......A.......... .......... out of............ .. ....... students

IPlease attach a copy of finalmarksheets/report cards for both years attested by Principalofyour JNVI