NAGPUR BRANCH OF WIRC OF ICAI
LATE SMT. SUNITA DEVI SURESH KUMAR AGRAWAL SCHOLARSHIP
APPLICATION FORM FOR GRANT OF SCHOLARSHIP
The Chairman,
FORM -1
Nagpur Branch of WIRC of ICAI,
“ICAI Bhawan”, Dhantoli,
NAGPUR – 440 012
Dear Sir,
I hereby apply for the grant of Merit-cum-Need Scholarship under the Nagpur Branch of WIRC
of ICAI Late Smt. Sunita Devi Suresh Kumar Agrawal Scholarship Scheme. I give below the relevant
particulars for your consideration. I understand that the information contained herein forms the basis for
consideration of grant of scholarship and that, if the information is found to be wrong, the scholarship
may be withdrawn immediately without prejudice to the recovery of the amounts already advanced to me.
1. Name in full
(CAPITAL LETTERS)
2. Registration No.
3. Date of Birth
4. Full Address
(a) Correspondence
PARTICULARS
Pin Code _
Affix
latest
photograph
(Passport
size)
(b) Permanent
Pin Code
_
Contact Number (s)
Email ID
5. (a) Father's/Guardian's Name
(b) Occupation (Service/Business/Other means of livelihood). Please furnish below the name
of the organization and designation of the post held, name of the firm and nature of business
carried on or other relevant particulars as may be applicable.
6. Total yearly income of parents/guardian from all sources (Write in words also)
(Ref. Form No. 2)
S.No.
Examination
Passed
Month & Year
Aggregate of
Marks Secured
Percentage
of Marks
Attempt Number
1
2
3
7. a) Particulars of passing the SSC/University Examination [enclose attested photocopy (ies)]
S.No.
Examination
Passed
Month &
Year
Aggregate of
Marks Secured
Percentage
of Marks
Name of the University/
Institution
1
2
b) Particulars of passing CPT / IPCC Course Examination of the Institute. [enclose attested
photocopy (ies)]
8. Name, Membership Number and address of the Chartered Accountant under whom the
candidate is receiving training under the Chartered Accountants Regulations. (if applicable)
Date and Year of Commencement
of Articles
Expected Date of Completion of
Articles
Date of First eligible attempt for
CA Final Exam
9. Whether Physically Challenged (If Yes, enclose attested copy of certificate issued by the Hospital
under the Central/ State Government)
10. List of the attested documents attached. Tick the Certificates attached.
(i) Marksheet of SSC/ University Examination
(ii) Marksheet of CPT/IPCC Examination.
(iii) Physically Challenged Medical Certificate, if applicable
I hereby declare that the statements made by me in this application form are true to the best of
my knowledge and belief. I further agree to abide by the terms and conditions of the award if I am
selected for the Scholarship applied for.
(Signature of the student)
Place
Date_
For students undergoing Articled Training
Certified that Shri/Ms.
clerk in our firm from
Was admitted as an articled/audit
and that he/she would be completing the prescribed
period of training under the Chartered Accountants Regulations on
Date_
Signature of the Member
Membership No. _
Name _
Name of the Firm _
Address
_
For students not undergoing Articleship
This is to certify that Shri/Ms.
CERTIFICATE
(Reg. No.
_) is continuing
to be a student of IPCC/Final Course of ICAI. His/her conduct has been found to be satisfactory.
Signature of the member of the Institute
(Membership No.) OR
Date :
Seal
Head of Educational Institution/Gazetted Officer
Address:
NAGPUR BRANCH OF WIRC OF ICAI
LATE SMT. SUNITA DEVI SURESH KUMAR AGRAWAL SCHOLARSHIP
FORM-2
Certificate of Income to be submitted by the Parents/ Guardian of the Applicant
I, father/guardian of
Who has applied for the grant
of Scholarship under the Nagpur Branch of WIRC of ICAI “Late Smt. Sunita Devi Suresh Kumar
Agrawal Scholarship Scheme”, declare that my total annual income, including the income of my
wife and of son/ward, in the preceding year ended 31
st
March, _______ was Rs. (in
Words )
(Signature)
Date
Name
(To be signed in the presence of a CA/Magistrate /Notary Public who would also affix his signature
and seal).
(Signature)
Date _______
(SEAL)
NAGPUR BRANCH OF WIRC OF ICAI
LATE SMT. SUNITA DEVI SURESH KUMAR AGRAWAL SCHOLARSHIP
FORM NO. 3
ADVANCE RECEIPT
Ref. No. :
PART-I
Received a sum of Rs. ( ) from the
Nagpur Branch of WIRC of the Institute of Chartered Accountants of India against ( Merit Cum Need –
Based Scholarship) / Endowments Scheme for the period from
to
(On revenue
stamp)
Signature of the
Student
Name: Reg. No.:
Full Address:
Contact No:
Date: Email ID:
For students undergoing Articleship *
PART-II
CERTIFICATE
This is to certify that Shri / Ms. (Articled Registration
No.
) is serving under me as Articled / Audit Clerk.
Dated:
Signature of the member
Name:
Membership No:
Address:
For students not undergoing Articleship *
PART-III
CERTIFICATE
This is to certify that Shri/Ms. (Reg. No. ) is
continuing to be a student of IPCC/Final of ICAI. His/her conduct has been found satisfactory.
Date: Seal
* Fill the Part-II or Part-III, whichever is applicable
Signature of the member of the Institute
(Membership No) OR
Head of Educational Institution/Gazetted Officer
Address:
