AZIM PREMJI SCHOLARSHIP
APPLICATION FORM
BASIC DETAILS
Personal Information
First Name : BHARTI Last Name : PATEL
Gender : Female Date of Birth : 27/6/2005
Mobile Number : 6266869172 Email Id :
[email protected]Aadhaar Number : 690299037348
Communication Address
State : MADHYA PRADESH District : DAMOH
Address for : Doli Post kaikheda Pin Code : 470775
Communication
REFERRAL DETAILS
Have you been referred by partners of the Azim Premji Foundation ?
No
EDUCATION DETAILS
Class 12 Details
Year of Passing : 2023 Mode of Education : Regular
State : MADHYA PRADESH District : DAMOH
Block : HATTA Pin Code : 470775
Name of the School : GOVT HSS KAIKHEDA Percentage : 82%
Class 10 Details
Year of Passing : 2021 Mode of Education : Regular
State : MADHYA PRADESH District : DAMOH
Block : HATTA Pin Code : 470775
Name of the School : GOVT HSS KAIKHEDA Percentage : 87%
Class 8 Details (Optional)
Year of Passing : Mode of Education :
State : District :
Pin Code : Percentage : %
SOCIO-ECONOMIC DETAILS (Optional)
Are you a specially : No Parental Status : Both Parents alive
abled person?
Mother's Name : Kalawati Father's Name : Mayaram
Annual Family Income : 0 to 2.5 lakh rupee Religion : Hindu
Category Name : OBC Community Name : OBC
ADMISSION DETAILS
State : MADHYA PRADESH District : DAMOH
Name of Institute : Shri Raghvendra Singh Course Type : Undergraduate Degree
Hazari Govt Degree
College, Hatta
Course Category : Science Course Name : Bsc
Course System : Semester Course Duration(In : 3
years)
Course Start Date : 06/2023 Which year of the : 1
course are you
currently studying?
CONSENT
Azim Premji Foundation (“Foundation”) collects information including Personal Information for the purpose of processing
your application and for awarding (if eligible) scholarship under the Azim Premji Scholarship Programme (“Purpose”).
The personal information (“Personal Information”) that we may collect includes but is not limited to your name,
parents’/guardian’s name, gender, address, mobile number, Aadhaar number, bank account details, academic records,
socio-economic information such as religion, community and family status.
The Personal Information collected from you may be retained by the Foundation for as long as may be required for
fulfilling the Purpose stated herein or as may be required by law. The Foundation uses reasonable data security and
safeguard measures to protect all Personal Information in Foundation’s possession. The Personal Information collected
from you by the Foundation shall not be disclosed to any third party without your consent.
By clicking on “I Agree”; you hereby provide consent to
· To provide your Personal Information for the purposes of Azim Premji Scholarship Programme.
· Cancellation of your scholarship in case this Personal Information is found to be incorrect/false at any time during the
course of this scholarship.
