Name of the student, Year, Branch & Roll No.         :
Univ. Reg. No.                                                            :
Place residing now (Tick one)                                    : College Hostel / with Parents / Elsewhere

Father’s Name, Occupation and Address      :
(Like Designation and Company where
working or self employed), with phone number

Father’s income
(Attach Income Certificate)                             :
Mother’s Name, Occupation and Address     :
(Like Designation and Company where
working or self employed) with phone number
Mother’s income (To be filled compulsorily) :
I Semester Grades / Marks (After Revaluation):                                Semester GPA:

Subject Code

Subject Name

Marks / Grades Obtained

Subject Code

Subject Name

Marks/ Grades obtained































Declaration & Undertaking by Student

I, Mr /Ms                                                                      hereby understand the terms and apply for the above LAPTOP SCHEME, as per details on the reverse.

I further solemnly declare that the particulars furnished above are correct and if they are found to be false, I agree to refund the entire cost of Laptop in one lump sum amount and accept any further disciplinary action as decided by the College in such cases.

Signature of the Student with date

Undertaking by the Parents/Guardians
I understand the terms of the Laptop Scheme and am allowing my son/daughter/ward as above to apply for the Scheme. I further undertake that the installments will be paid within the due dates, as laid down by the College, without fail.

                                                                                             Signature of the Parent with date

Faculty Adviser’s Signature :
(in confirmation of having verified the Grades & GPA )      

Remarks of HoD and Signature: