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Office use – Student ID

THE LILY FOUNDATION

125/10/1 Chander Village Road, Haridevpur Kolkata – 700 082

2015-2016 Application for High School/ College SMILE © Scholarship

V28 total 5 pages Revised: 24 February 2015

Attention Applicant: Please read thoroughly the Rules, Requirements and Explanations of Items on Page 5 and on. Fill the application in English – use all CAPITAL. Incomplete applications will be discarded without consideration and without any notice sent to you. If you need assistance in filling the form, call Lily office at 033-2311-6773.

DO NOT LEAVE ANY FIELD BLANK.

Keep Page 5 and on for your reference only -do not send with the application. The only-acceptable version of the application form is the one currently available online. Earlier versions are not acceptable. If online download is not feasible call or visit the Lily office for a form. Our acceptable application forms are never available in shops.

Note Cut-off Dates: Application Receipt 30 May; Annual Result 30 May;

Mentor Evaluation 10 January; Thanks to Sponsor 10 January;

Winter Book Report 10 January; Summer Book Report 30 June;

ALL APPLICATIONS NEED BE ENDORSED BY AREA-REP SIGNATURE BELOW. CONTACT LILY OFFICE FOR QUESTIONS.

1. Student Name

(First) _________________________ (Middle) _______________ (Last) __________________

2. Contact telephone Number: ( )

- include Area Code

Reserved space for Administrator [student not to write here]	Info verified. Other comments….
	Area rep initial & date

Page 2 of 5

Student Info:

3. Sex: Male/female 4. Birthdate _____(yr)/____(mo)/____(day)

5. Your current Class [or College year]: _________ in academic year: 20__ - 20__

5A. When will you graduate Higher Secondary [or College final] ? Month______ Year ______

6. Total number of students in Class:______

7. In class, your Rank (position -not roll no.) : _______ OR division (Secon/ HS) ______

7A. Your last annual exam score in % (you calculate – exclude optional subject) ___________

8. You belong to the stream [Sci/ Arts/ Com/ General]: __________

College Students (circle below):

BA/ BSc/ BCom/ BE/ MBBS/ GNM/ Others – name: _______________

9. Do you receive any scholarship or 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:

11. High School/ College name:______________________________________________

12. Address (include PIN code): _______________________________________________

_______________________________________________

_______________________________________________

_______________________________________________

13. Email address (if any): ___________________________________________________

14. Principal/ Headmaster’s name: ______________________________________________

Family Info:

15. Father’s name: ___________________________________________

Occupation (expound): _____________________________________________

** Application may be rejected if it is not clear to us about nature of the job

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 with them? _______________

___________________________________________________________

Page 3 of 5

20. References (name two respectable persons –at least one in teaching profession- who know you well)

Name:	Name:
Position:	Position:
Address (include PIN):	Address (include PIN):
Day-time Phone: Email:	Day-time Phone: Email:
Signature Initials ____________ Date ______	Signature Initials ____________ Date ______

21. How do you want to use the money (assume you get Rs. 600/- a month or college Rs.1500/-))?

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. I have no objection if the foundation uses my data for its promotion.

___________________________

Applicant’s full signature Date ___/___/___

-----------------------------------------------------------------------------------------------------------------------------

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.

[Say about your involvement even if you didn’t earn any credit or don’t have any testimonials]

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:

3. What are your hobbies?

4. What do you want to be when you grow up (your goal in life)? [Add page if you need]:

___________________________________________________________________

Rev. ymd 150225

Please remember to update India Office [Subir Mitra, The Lily Foundation, 125/10/1 Chander Village Rd., Haridevpur, Kolkata – 700 082 (WB)]

with your latest achievements using a copy of this form or a blank paper when you send annual result.

Page 5 of 5

THE LILY FOUNDATION OF AMERICA INC.

Rules

1. The scholarship award is for a High School student (9^th, 10^th, 11^th, 12^th 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 (10^th Gr for Secondary or 12^th Gr for Higher Secondary) or the college years. However, it needs to be endorsed for continuation 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 or false 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).

6. The foundation has the right to use student -provided data in the application and data generated in the following years after the first award for its own promotion (including marketing).

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. In student’s own hand-writing One-page request-letter 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 India office (or US office for outside India students) within two weeks of distribution. Better grades are expected every year. If there were any additional extra-curricular activities during the year, then submit an update in the supplement form. NON-RECEIPT OF ANNUAL RESULT WILL AUTOMATICALLY CANCEL THE AWARD. Note: For 11^th Graders promoted to 12^th Grade, sending a testimonial (annual marksheet or Headmaster’s letter testifying the student is enrolled in the 12^th Grade and no exam conducted) to the foundation in time will be considered in absence of a marksheet.

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. Change of school info from Secondary to Higher Secondary MUST be informed. Notify immediately if the student does not plan to appear at a scheduled exam. Failure of this requirement automatically forfeits the possibility of award continuation.

F. All communications with the foundation initiated from the student side must be by 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, example, BE-Electrical 1^st year, 2^nd year etc.;

Item 5A: Your expected date of completion of the full term

Item 7: If exact rank is not available, then provide estimate, such as 30th out of 80, or a percentile, such as top 10%. Ranked list puts the student with the highest marks as No. 1.

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, explain nature of job such as share-cropper, small farmer, vegetable vendor, clerk in a govt organization, private tutor, small business owner, hawker, taxi-driver, tea-stall owner, house maid, cook in restaurant etc. Avoid vague description such as service in a private firm.

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. At least one Reference should be from teaching profession. If you want to change any Reference later, you may inform the office giving two new names with details and briefly explain WHY you needed to change.

Item 21: Keep receipts as you go for verification by the office on demand.

Item 22: If you do not have a bank account in your name, try opening one. Else, 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 Mentor. One of the two references may be chosen if others are not available.

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

________________________________________

1. Have you filled the application fully by yourself using your own hand-writing?
2. Are all items in the form answered?
3. Have you stated all family members’ relationship with you?
4. Have you enclosed Headmaster’s recommendation letter?
5. Have you enclosed Family Income Certificate from Panchayat or equivalent govt. authority?
6. Have you given your contact telephone number?
7. Have you enclosed a certified photocopy of the most recent annual exam report card?
8. Have you enclosed a letter in a plain paper written by you in your own hand-writing justifying why you deserve the scholarship?
9. Are References’ phone numbers provided? Is one of them your Headmaster or a school teacher?
10. 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.

* * *

END-OF-APPLICATION