+ Application Form For Educational Help
KHIMJI BHAGWANDAS CHARITY TRUST
Lohana Bhuvan, Paliram Road, Behind Municipal Office,
Andheri (West), Mumbai - 400 058. Tel. C/o. 2628 3715.
Office Address : Raghuvanshi Mansion, Block No. 20, Raghuvanshi Mills Compound,
11/12, Senapati Bapat Marg, Lower Parel (west), Mumbai - 400 018. Tel. : 2498 2664
E - Mail : trustees@khimjibhagwandascharitytrust.org   Website : www.khimjibhagwandascharitytrust.org
All details marked below must be clearly state by the applicant end no column must be left blank.   
Full Name (Surname First) :   
Present Address For Correspondence :
Telephone No. :
Permanent Address :
Age :
Date of Birth :
Marital Status :
Details of school Carrier (Full details expected - lf necessary give details on separate sheet)
Name of School University / Board Last Exam Passed Year UNIVERSITY / BOARD
Class Name Percentage
             
Details of University Career
Name of College University Degree / Diploma Exam Passed SUB YEAR UNIVERSITY / BOARD
Class Name Percentage
 
Any Special Distinction / Scholarship Obtained :
Post Graduate & Research Work (lf Any) :
Experience / Practical Training (lf Any) :
Employer's Name (lf Any) :
Telephone No. :
Present Salary(In Rs.) :  Per Month.
 
PROPOSED COURSE OF STUDY YEARS REQUIRED COST P. A.
TUTION BOARDING & LODGING
Admission Has Been { Secured at  
{  
{ Sought at  
{  
Total Amount of Scholarship required from KHIMJI BHAGWANDAS CHARITY TRUST
Rs. Amount Desired to this Term /Year :
lf You have applied for Assistance / Scholarship to any other Trust / lnstitute :
NAME OF THE TRUST & ADDRESS AMOUNT REQUESTED AMOUNT SANCTIONED
Details regarding person who will guarantee payment & repayment of the Scholarship
Name & Full Address Occupation lncome Per Month Rs. Relation to Applicant Telephone No

Name & Address of 3 reference under whom the applicant has studied or worked or is personally Known
Name & Full Address
 
Family lnformation (Please Fill All the Columns)
Family Members Name Age Education Employment / Occupation Gross Annual lncome
Father
Mother
Other Earning Member
Other Earning Member
Other Earning Member
Employer's Name & Address ln Full (of Father or any Earning Member) :
Occupation :
Salary Rs. :  Per Month.
           
 + Applicaiton Form For Medical Help
KHIMJI BHAGWANDAS CHARITY TRUST
Lohana Bhuvan, Paliram Road, Behind Municipal Office,
Andheri (West), Mumbai - 400 058. Tel. C/o. 2628 3715.
Office Address : Raghuvanshi Mansion, Block No. 20, Raghuvanshi Mills Compound,
11/12, Senapati Bapat Marg, Lower Parel (west), Mumbai - 400 013. Tel. : 2498 2664
E - Mail : trustees@khimjibhagwandascharitytrust.org   Website : www.khimjibhagwandascharitytrust.org
All details marked below must be clearly state by the applicant end no column must be left blank.   
Name of the patient :   
Age :
Address of the patient :
Type of Illness :
Name and Address of the doctor for the first treatment :
Address of the patient residing near the hospital :
Approximate Medical expenses to be incurred :
Name and Address of the hospital where patient is admitted :
Mode of Payment for hospital expenses :
Receipt number of Hospital Bill :
  Information on Financial and relatives of the Patient
No of person in patients family :
Nature of Business of the patient :
Annual Income of the patient and his family :
Any help received from the other trust :
Name and Address of the person introduced to this trust :