ALL INDIA CONFEDERATION OF THE BLIND
Braille Bhawan, Institutional Area, 
Sector-5, Rohini, Delhi – 110 085
Phone:    011-27054082 						Email: aicbdelhi@yahoo.com  
       Tele-fax: 011-27050915 							       Website: www.aicb.in

“APPLICATION FORM FOR THE “KRISHNA KUMARI VARMA MEMORIAL AWARD”

PERSONAL DETAILS 

1)  Full Name in Block letters		:  _______________________________________________

2)  Date of Birth				: ________________________________________________

3)  Present Postal Address		: ________________________________________________
    					  
         ________________________________________________

		  			  ________________________________________________
					
					  
4)  Permanent Address 			:  ________________________________________________

					   ________________________________________________

					   ________________________________________________

5)  Phone/Mobile Number		:  ________________________________________________

6)  Fax					:  ________________________________________________

7)  Email 				:  ________________________________________________

8)  Onset of Blindness			:  ________________________________________________

9)  Present status of Eye sight 		:  ________________________________________________

EDUCATIONAL QUALIFICATION
10)  Matriculation or Equivalent Examination  
      a)  Name of the Board or University	: ________________________________________________
      b)  Year				: ________________________________________________
      c)  Division				: ________________________________________________
      d)  Percentage of Marks		: ________________________________________________
11)  Higher Secondary or Intermediate Examination
      a)  Name of the Board or University	: ________________________________________________
      b)  Year				: ________________________________________________
      c)  Division				: ________________________________________________
      d)  Percentage of Marks		: ________________________________________________

12)  B.A. or Equivalent Examination 
      a)  Name of the Board or University	: ________________________________________________
      b)  Year				: ________________________________________________
      c)  Division				: ________________________________________________
      d)  Percentage of Marks		: ________________________________________________

13)  M.A. or Equivalent Examination
       a)  Name of the Board or University	: ________________________________________________
      b)  Year				: ________________________________________________
      c)  Division				: ________________________________________________
      d)  Percentage of Marks		: ________________________________________________

14)  Participation in co-curricular activities, such as Debate Competition, Essay Writing Contest, Elocution       
       Contest, etc. (Please give details on a separate sheet) :

15)  Any other special achievement s	:

16)  Signature of the Applicant		:	

Note:
1)  Photocopies of the certificates of all the examinations duly attested by the Head of the Department concerned or a Gazetted Officer.
2)  A certificate testifying the position of the candidate in order of merit in the University should also be sent along with the application form and this certificate should be signed by (A) the Head of the Department or (B) the Registrar or Vice-Chancellor of the University.