FORM FC-5





INTIMATION TO THE CENTRAL GOVERNMENT OF RECEIPT OFSCHOLARSHIP, STIPEND OR ANY PAYMENT OF A LIKE NATURE FROM A FOREIGN SOURCE



[See rule 4(c)][Sections 7(1) and 7(2) of the Foreign Contribution (Regulation) Act, 1976]



1. Name in full (in block letters)

2. Date of birth

3. Name of father

4. Present address

5. Permanent address

6. Passport particulars

7. Specific details of occupation/profession

8. Particulars of the foreign source from whom scholarship, stipend or payment of a like nature was received:

(a) If an individual, his personal particulars including name, (a)

present address, permanent address, nationality, profession

(b) If an organisation/institution/association/trust/foundation/ (b)

trade union, etc., full particulars thereof including:—

(i) Full name and complete address (i)

(ii) Address of head office/principal office (ii)

(iii) Aims and objects (iii)

(iv) Particulars of important office bearers (iv)

9. Nature and full details of scholarship, stipend or any payment of a like nature received from foreign source, indicating (a) total amount and its break-up under various heads like cost of journey, equipment, clothing, maintenance, tuition fees, residence fees, books, etc., and (b) mode/channel of receipt

10. Purpose of the scholarship, stipend or any payment of a like nature with specific details of courses attended/to be attended

11. Duration of stay abroad with dates

12. Any other information of significance, which the applicant may like to furnish

DECLARATION



I hereby declare that the above particulars furnished by me are true and correct.

Place..........

Date.........

Signature of the applicant