APPLICATION FORM

1 Personal Details

Name of the student

Gender

Date of Birth (DD-MMM-YYYY)

Current Class

% marks or Grade obtained in the last class

Father's / Guardian's Name

Landmark

City / District

StatePin code

ECSS- Educational Crisis Scholarship Support

An initiative of HDFC Bank Education is the investment our generation makes in the future-Mitt Romney

Mother's NamePlease state the relationship in case of Guardian

Residential Address (please write the complete postal address)

Affix recent color photo of the student and sign across the photograph

Student Category

Specialization (If any)

2 Contact Details

Phone # (Landline with STD)

Phone # (Mobile)

Name of the member Relation with the child Age Education Occupation Annual Income

Total Annual Income

Single parent child

Differently able child

No. of dependant members (No.of non-earning members)

Type of family (Please tick any one option)

4 Socio-economic Details

A Destitute/orphan

3 Family Details

If Yse,Specify Year of Death:

If Yes,Specify Year of separation/death:

If Yes,Specify:

Socio-economic Details

If yes, please Specify name of disease/illness: Year of detection:

Undergoing treatment at:

Crisis such as disaster/accident/loss of job,etc.

B Total Annual income of the family from all the sources is

Specify…………………………..

C Nature of dwelling/house

if Yes,Year of occurrence :

Less than Rs. 50000

Between Rs.50000 to Rs.1.5 lakhs

Between Rs.1.5 lakhs to Rs.2 lakhs

Between Rs.2 lakhs to Rs.3 lakhs

Rs. 3 lakhs & above

Select

Parents/child/siblings suffering / under treatment for life threatening illness

5 Institute Details

A Name of the school/College/University

B Type of College/University

C Recognized by

D Annual School/College/University Fee

E

F Landmark

G City/District

H

I Pin Code

J Phone No. (with STDCode)

6

A

7 Previous scholarship

Complete address of School/college/ university (please write the complete postaladdress)

Name in which the cheque needs to be drawn (Please ensure that the full name of the Institution is correctly mentioned))

Name of the School/College/Trust/Society/Foundation

(Eg. ABC Education Trust/XYZ College of Technology,etc.)

A Have you applied for ECSS Scholarship before?

If so, which year?B Specify

C Have you received the ECSS scholarship before ?

State

D If so, which year? Specify

8 Briefly describe the reason of applying & impact of scholarship on the child's education

9

Name of the person Relationship with the applicant Email Id (if any)

E Is any other sibling (own brother/sister) applying for the Scholorship ?

Please provide two references (Referees cannot be friends or relatives)

Tel. no. (with STD Code)

Occupation(e.g Businessman)

F if Yes, Name of the sibling (own brother/sister)

(Mandatory for Manual submission)I (Guardian Name)______________________________________________certify that the information in this application is accurate and true and further, I agree to all the conditions .

Signature/ Thumb impression

Date

Place __________________

School/College/University authority signature __________________Reccommended by __________________

_______________________________________________________

__________________

Nearest HDFC Bank Branch

Branch Verification

ensure that the following documents are securely attached and put a tick (√) wherever applicable.

OR

Income proof from employer (Annexure IA). In case of self employment, self attested income declaration. (Annexure IB)

Verification certificate from school (Annexure IIA) duly stamped and signed by school authoirty

Verification certificate from college/university (Annexure IIB) duly signed and stamped by college/university authority

Any 2 Address Proof (Aadhar-UIAID Card) Electricity Bill

Submission: The Branches are requested to send the Application Forms at the following address:

Ration Card Passport Phone bill

Name of the nearest HDFC Bank branch Branch Code

10

Branch Code

Required only for manual submission

Student’s last academic year’s report card

Corporate Social Responsibility, HDFC Bank,Alpha Building, I-Think Techno Campus, 9th Floor, Kanjurmarg-East,Mumbai-400042, Maharashtra,India

Branch Name:________________________________Signature of Branch Manager_________________________

Name of Branch Manager____________________________

Employee Code___________

Location:__________________________

Date:_____________________

Stamp