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Office use – Student ID
THE LILY FOUNDATION OF AMERICA INC
Application for High School/
College SMILE © Scholarship
V21 total 5 pages
Revised: 15 July 2010
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Attention
Applicant: Please read thoroughly the Rules, Requirements and
Explanations of Items on Page 5. Fill the application in English – try using
all CAPITAL letters. Incomplete
applications will be discarded without consideration and without any notice
to you. DO NOT LEAVE ANY FIELD BLANK. Keep a copy of Page 5 as your record for
future reference. Don’t include in application. Note Cut-off
Dates: Application Receipt 30 May; Annual Result 30 May; Winter
Book Report 10 January; Summer Book Report 30 June;
Half-yearly (2nd terminal) Result- As Available or 30
December |
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1. Student Name (First) _________________________ (Middle)
_______________ (Last) __________________ 2. Contact telephone Number: ( ) - include Area Code |
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Reserved space for Administrator [student not to write here] |
Info verified. Other comments…. |
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Area rep initial & date |
Page 2 of 5
Student Info:
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3. Sex: Male/female 4. Birthdate _____(yr)/____(mo)/____(day) 5. Class (or Grade)/[College year]: _________ in academic year: 20__ - 20__
6. Total number of students in Class:______ 7. Your last annual exam rank (not roll no.) in Class: _______ OR division (Secon/ HS) ______ 7A. Your last annual exam score in % (you calculate – exclude optional subject) ___________ 8. Stream [Sci/
Arts/ Com/ General]: __________ College Students (circle): BA/ BSc/ BCom/ BE/ MBBS/ Others –
name _______________ 9. Do you receive any scholarship/stipend (SC/ST
grant included) now? (Yes/No)
________ 10. If yes (in
No.9), how much per month (you calculate)? Name of Grant________________
Rs.__________ |
School/ College Info:
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12. Address (include PIN code): _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ 13. Email address (if any): ___________________________________________________ 14. Principal/ Headmaster’s name: ______________________________________________ |
Family Info:
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15. Father’s name: ___________________________________ Occupation: _____________ 16. Mother’s name: ___________________________________ Occupation: _____________ 17. Home Address (include PIN code): ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ 18. Total Monthly Family Income (add incomes from both parents and other resources): Rs.___________ 19. How many persons in the household and your relationship? ________________________ ___________________________________________________________ |
Page 3 of 5
20. References (name two respectable persons with addresses and phone numbers who know you well)
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Name: |
Name: |
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Position: |
Position: |
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Address: |
Address: |
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Day-time Phone: Email: |
Day-time Phone: Email: |
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Signature Initials ____________ Date ______ |
Signature Initials ____________ Date ______ |
21. How do you want to use the money (assume you get Rs. 500/- a month)?
Private Tutor (Rs.) _______ Books & Stationery (Rs.) _______ Transportation (Rs.) ________
School uniform (Rs.) ______ Other – you mention (Rs.) _____________
22. How do you prefer to receive the money (select one)?
___ Cheque (if you prefer a payee other than yourself, mention name and address below)
___ Any other way? (you mention)
The above statements are true to the best of my knowledge. I understand that in the event any info
provided here is proved false I may loose my scholarship without receiving any advice from Lily.
I undertake to abide by the rules of Lily Foundation.
___________________________
Applicant’s full signature Date ___/___/___
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Approved /Disapproved - Comments:
_________________________________
President, Lily Foundation Date___/___/___
______________________________________________________________________________
Page 4 of 5
Application Supplement Form
Extra-curricular Details
_________________________________________________________
1.
Student Name:
2.
Describe your involvement (only recent three in each group – attach
testimonials) in detail.
A.
Activities in
Community (include timeframe – Year/ Month):
[Provide short description of your leadership/ participation]
Accomplishments
(prizes, medals, certificates):
B.
Activities in
School/ College (include timeframe – Year/ Month):
Accomplishments
(prizes, medals, certificates):
C.
Activities
elsewhere (include timeframe – Year/ Month):
Accomplishments
(prizes, medals, certificates):
D.
Help at home:
- What are your hobbies?
- What do you want to be when you grow up (your
goal in life)? [Add
page if you need]:
___________________________________________________________________
Rev. ymd 080820
Page 5 of 5
THE LILY FOUNDATION OF AMERICA INC.
Rules
1.
The scholarship award is for a High School student (9th, 10th,
11th, 12th Grade)
or a college student.
2.
The Board of Directors decision is final on candidate selection.
3.
The scholarship is normally awarded for the current full academic year, which
is likely to be continued through the end of the High School grades (10th
Gr for Secondary or 12th Gr for Higher Secondary) or the college years. However, it
needs to be endorsed by the foundation every year.
4.
The foundation retains the authority to cancel the scholarship any time during
the year if there is a reason, such as inaccurate info in the application,
wrong conduct during the year etc. Any incomplete answer against any item
automatically assumes the lowest point possible.
5.
The scholarship is a non-refundable grant (part refundable for college) that
will be spent toward the student’s tuition, books, transportation and other
education-related costs. College students sign 50-50 Regift
promissory note (contact office)
Requirements
A.
The student must
completely fill the application (except for the approval) in OWN English
hand-writing. DO NOT LEAVE ANY ITEM
BLANK. Applications filled by others’ hand-writing will be rejected.
B.
The application
for the scholarship must accompany the following as attachments:
1. One recent passport-size face-only
photograph of the student – write name on the back
2.
[If possible] one
photograph of the family in front of the family house
3.
Original or a
photocopy of the student’s last annual exam report card from the school
[Translate/ annotate in English if it is in another language]. DO NOT SEND
EARLIER YEARS’ REPORT CARDS.
4.
On Application
Supplement Form write the student’s involvement in community, school and home
activities – attach testimonials. Examples of these activities are: Organize
blood donation camp, lead environment cleaning, Sports team member or
captain, Organize clubs /associations;
Participate in dramas or Play musical instruments; Help family by earning money
etc. Send testimonials as you keep achieving.
5.
Headmaster’s
recommendation [If unavailable, state the reason on a separate sheet, and send
two recommendations instead - one from your teacher-in-charge and one from a
respectable person who knows your family personally.] Note, recommendation
is not a character certificate.
6.
One-page
hand-written application by the student explaining why he/she deserves this
scholarship.
C.
[Continuity Clause] After every year’s
final exam, the student MUST send the original or a photocopy of the report
card attested by a teacher to the foundation’s
D.
[Co-curriculum
Clause] Each student should write during two vacations every year at least 2
book-reports (one in summer and one in winter) on books of at least 100 pages
on lives of great personalities in the world and send them to India Office.
Essays on contemporary issues are also acceptable instead of a book-report.
E.
The student must
immediately report to the foundation any change of home address, school/college
change name and address or dropping out of school for any reason. Notify
immediately if you do not plan to appear at a scheduled exam. Failure of this
requirement will be viewed severely.
F.
All communications
with the foundation initiated from the student side must be from the student
himself/ herself (not parents) unless the foundation has requested in a
different manner. English is the medium of communication.
G.
Supporting
documents and testimonials, not originally written in English, should be
translated into English. Annotation only translation is also acceptable instead
of full translation.
Note: Your provided data may be
utilized by the foundation for fundraising.
Explanation of Items in the Application
Item 2: If you cannot be
contacted by this number through repeated attempts, your application is liable
to cancellation.
Item 5: State the college year
as 1st year, 2nd year etc.
Item 7: If exact rank is not
available, then provide estimate, such as 30th out of 80.
Items 12, 13, 17, 20: Provide
full address including P.O. , District, State and PIN code. Also provide email
address when possible.
Item 14: Do not put any
other teacher’s name please.
Item 15: Be specific in
occupation, such as share-cropper, small farmer, vegetable vendor, clerk in a govt organization, private tutor, small business owner,
hawker, taxi-driver, shop owner etc.
Item 18: You must include a
salary certificate/ income certificate from appropriate authority, namely,
employer, Panchayat or an equivalent govt. body.
Item 20: References should not
be related to you and should be holding positions of responsibility. You must
include contact phone numbers. References should sign (initial) to show their
consent.
Item 21: Keep receipts as you
go for verification by the office on demand.
Item 22: Since it is possible
that the student does not have a bank account, you may provide an alternate
payee name and address where the cheque should be
mailed to.
Note: Testimonials are
important, but providing extra documents not expressly asked for here will be
considered lack of understanding on your part and thus a disqualification.
NEVER MENTION YOUR CASTE OR RELIGION ANYWHERE.
Foundation
Officials, please note:
1.
DO NOT consider an
application that is not filled properly and completely.
2.
DO NOT consider an
application that has any missing (A, B) requirements.
3.
Select a
4.
Disposition
applications with comments –
particularly those not approved.
5.
Emphasize on
Headmaster’s/ Principal’s comments – Academic strength, Economic background and
Extra-curricular activities.
6.
Administrator,
precisely determine the school-year [college year], class and % of total score
or grade average in the submitted mark-sheet. Next year’s review will compare
against this score.
* * *
SMILE Scholarship Application
10-point Checklist
_________________________________________________________
- Have you filled the application fully by yourself using your own hand-writing?
- Are all items in the form answered?
- Have you stated all family members’ relationship with you?
- Have you enclosed Headmaster’s recommendation letter?
- Have you enclosed Family Income Certificate from Panchayat or equivalent govt. authority?
- Have you given your contact telephone number?
- Have you enclosed a certified photocopy of the most recent annual exam report card?
- Have you enclosed a letter in a plain paper written by you in your own hand-writing justifying why you deserve the scholarship?
- Are References’ phone numbers provided? Is one of them your Headmaster or a school teacher?
- Have you read and understood Page 5 of the form fully?
If any of the items in the above 10-point checklist is NO, then DO NOT SUBMIT the application.
* * *
V21
15 july 2010