JAWAHAR NAVODAYA VIDYALAYA, MUNDALI, DIST-CUTTACK (ORISSA)

Transcription

1 JAWAHAR NAVODAYA VIDYALAYA, MUNDALI, DIST-CUTTACK (ORISSA) APPLICATION FOR ADMISSION IN CLASS VI Admission No : Date of Application : 1. Full Name of the Pupil : (IN CAPITAL LETTERS) 2. Full Name of Father : 3. Full Name of Mother : 4. Nationality of the candidate : 5. Religion of the candidate : 6. Mother Tongue of the candidate : 7. Sex : BOY / GIRL Category : GEN / OBC / SC / ST (RURAL / URBAN) 8. Date of Birth (Figure) / / (Words) ) 9. Age at the time of Admission : Years and months 10. Present Address : 11. Permanent Address : PIN Tele No PIN Tele No PASTE PASSPORT SIZE OF CANDIDATE 12. Name & Address of Local Guardian : relationship and address : & telephone Number : 13. Name of the Previous School : with Address 14. Whether belongs from BPL Category(Yes/No) (if yes, attach attested copy of BPL Card) DECLARATION BY THE PARENTS 1. I hereby declare that the date of birth in respect of my son/daughter/ward furnished by me in column No. 8 is correct and that I would not demand any change in it. 2. I shall abide by the Rules of the Vidyalaya. 3. If my ward will be indulged any type of indiscipline, necessary action may be taken by the Vidalaya administration against him/her. Date : (Signature of Parent/Guardian) CLAUSE Samiti will charge initially Rs. 200/- per student per month (which may gradually increase to Rs. 300/- per month) from the students of class IX and above, excluding SCs / STs, Girls and Students whose families are Below Poverty Line. Date : (Signature of Parents/Guardian)

2 JAWAHAR NAVODAYA VIDYALAYA, MUNDALI, CUTTACK (ORISSA) CANDIDATE DETAILS FORM (BIO-DATA) (Fill this form by the Parent/Guardian with the help of the Headmaster of that School from where the candidate has passed CLASS V) 1. Name of the Candidate : (In BLOCK CAPITAL Letters) 2. Sex (Boy/Girl) : 3. Category : GENERAL/ O B C / SC / ST : 4. URBAN / RURAL : 5. Religion : 6. Date of Birth : Date Month Year PASTE RECENT PASSPORT SIZE OF THE CANDIDATE 7. Name of Parents : FATHER MOTHER 8. Name of the Guardian and relation with the student, if father is not Guardian :- Name Relationship 9. Name of the School/Schools from where candidate has passed class 3 rd, 4 th & 5 th Sl No Particulars CLASS 1. (a) Month & year of Admission III IV V (b) Month & Year of Passing 2. (a) Name of the School (b) Name of VILLAGE & TOWN where school is situated At PO At PO At PO PS PS PS Dist Dist Dist PIN PIN PIN 3. Is it recognized (YES or NO) 4. Name of BLOCK 5 Name of DISTRICT 6. Is the School is situated In RURAL/URBAN (Signature of Parent)

3 CERTIFICATE (BY PARENT OF GUARDIAN OF THE CANDIDATE) Certified that the information given above is true to the best of my knowledge and belief. In case any part of the information furnished by me is found incorrect or false, the admission of my child/ward may be cancelled. I am ready to produce relevant certificates issued by the competent authorities as and when asked for. Date : (Signature of Parent/Guardian) ******************************************************************************* CERTIFICATE (BY THE HEAD OF THE SCHOOL WHERE THE STUDENT STUDIED IN CLASS V) Certified that the information given above are true as per school records. It is also certified that Master/Kumari Son/daughter of was admitted in this School in Class on and passed Class V during the year i.e. on. Date: (Signature of Headmaster with Office Seal) N.B.:- THE HEADMASTER OF THE SCHOOL IS REQUESTED TO VERIFY ALL THE ENTRIES PERSONALLY Name of Headmaster UNDERTAKING (To be signed by the Father (by the Guardian in case father is not alive) in the presence of the Principal, Jawahar Navodaya Vidyalaya, Mundali, Cuttack (Orissa) I father of who has been selected for admission to JNV, Mundali, Cuttack am hereby undertake that I would have NO OBJECTION if my son/daughter/ward is transferred from this JNV to another in any other Linguistic State as per the provision of the scheme of Navodaya Vidyalaya Samiti. Further I declare that I shall abide by the conditions that if my son/daughter/ ward does not move to another school, he/she will not be allowed to continue to stay in Navodaya Vidyalaya further and his/her studies would be discontinued. Date : PRESENT ADDRESS:- (Signature of the Father/Guardian) Name PERMANENT ADDRESS: Date : SIGNED IN MY PRESENCE Signature Name PRINCIPAL, JNV, MUNDALI,CUTTACK (OFFICE SEAL)

4 Admission No JAWAHAR NAVODAYA VIDYALAYA, MUNDALI, CUTTACK (ODISHA) SOCIO ECONOMIC DATA Category Sex FOR OFFICE USE ONLY (To be filled by the parent / Guardian) Date of Admission Area 1. Name of the Candidate : 2. Name of :- FATHER : MOTHER : 3. Date of Birth of student : 4. Address :- PRESENT ADDRESS PERMANENT ADDRESS VILL : POST : P.S. : TEH : DIST : STATE: PIN : TELE NO: VILL : POST : P.S. : TEH : DIST : STATE: PIN : TELE NO : 5. Area : RURAL / URBAN 6. SEX - GIRL / BOY 7. Category : GENERAL / O B C / S C / S T 8. FATHER MOTHER Qualification of Occupation of Yearly Income of 9. No of Family members : 10. Route of JNV, Mundali from : Student s Home : 11. Fare, Distance & Nature of Transport : Rs. Km By 12. Full Name and Address (other than parents) of two persons whom the parents may authorized to bring and meet their Son/Daughter. Please note that no person other than except these two persons will be permitted to meet the student:- a. Name Signature Address b. Name Signature Address Signature of Candidate Signature of Father Signature of Mother

5 JAWAHAR NAVODAYA VIDYALAYA, MUNDALI, CUTTACK (ODISHA) Photograph Identification of Parents/Guardians Name of the Student : (Capital letters) Category : GEN/ OBC / SC / ST AREA : RURAL / URBAN SEX : BOY / GIRL Address : PRESENT : PERMANENT : NAME OF FATHER NAME OF MOTHER NAME OF GUARDIAN OF FATHER OF MOTHER OF GUARDIAN (FOR OFFICE USE ONLY) HOUSE ALLOTTED NAME OF HOUSE MASTER /HOUSE MISTRESS (Signature of Admission I/C) Name has been entered in Page No. of. House Attendance Register. (Signature of Housemaster/House Mistress)

6 JAWAHAR NAVODAYA VIDYALAYA, MUNDALI, CUTTACK (ODISHA) (Students Information Proforma) (This Proforma to be kept in the safe custody of the Housemaster and one copy to be retained in the Vidyalaya Office) Student s Admission Register No. 1. Name of the Student : Psssport size photographs of the Student 2. Date of Birth : / / 3. Mark of Identification : 4. Home Address :- Present : Permanent: 5. Contact Phone No (with STD Code) 6. Father s Name : 7. Annual Income of Family: 8. Information about own Brothers & Sisters :- Sl No Name Age Education Married/unmarried Important information about the student which needs Special Attention :- 10. Main Hobbies of the Student 11. Date : Signature of Mother/Father Date : Signature of student 12. Name of Present House 13. Present Class and Section Signature of Housemaster with date AFTER THREE YEARS Signature of Principal with date

7 JAWAHAR NAVODAYA VIDYALAYA, MUNDALI, CUTTACK (ODISHA) Photograph Identification of Parents/Guardians Name of the Student : (Capital letters) Category : GEN/ OBC / SC / ST AREA : RURAL / URBAN SEX : BOY / GIRL Address : PRESENT : PERMANENT : NAME OF FATHER NAME OF MOTHER NAME OF GUARDIAN OF FATHER OF MOTHER OF GUARDIAN (FOR OFFICE USE ONLY) HOUSE ALLOTTED NAME OF HOUSE MASTER /HOUSE MISTRESS (Signature of Admission I/C) Name has been entered in Page No. of. House Attendance Register. (Signature of Housemaster/House Mistress)

8 JAWAHAR NAVODAYA VIDYALAYA, MUNDALI, CUTTACK (ODISHA) (Students Information Proforma) (This Proforma to be kept in the safe custody of the Housemaster and one copy to be retained in the Vidyalaya Office) Student s Admission Register No. 1. Name of the Student : Psssport size photographs of the Student 2. Date of Birth : / / 3. Mark of Identification : 4. Home Address :- Present : Permanent: 5. Contact Phone No (with STD Code) 6. Father s Name : 7. Annual Income of Family: 8. Information about own Brothers & Sisters :- Sl No Name Age Education Married/unmarried Important information about the student which needs Special Attention :- 10. Main Hobbies of the Student 11. Date : Signature of Mother/Father Date : Signature of student 12. Name of Present House 13. Present Class and Section Signature of Housemaster with date AFTER THREE YEARS Signature of Principal with date

9 JAWAHAR NAVODAYA VIDYALAYA, CUTTACK (ODISHA) MEDICAL EXAMINATION REPORT (To be obtained from any Central/ State Government Hospital) 1. Name of the Candidate 2. Father s Name 3. Mother s Name 4. Date of Birth 5. Present Address 6. Permanent Address 7. Identification Marks Height cm Weight Kg 9. Certificates for the following Medical Examination Reports are required to be submitted alongwith all other documents:- a) Blood Group - b) CBC c) Vision Testd) Urine 1) R.E & 2) M.E e) Stool 1) R.E & 2) M.E Remarks of Medical Officer Certified that the above candidate is found medically fit/unfit for admission in Class at Jawahar Navodaya Vidyalaya, Mundali, Cuttack (ODISHA). (Signature of Medical Officer)

10 RESIDENCE CERTIFICATE (To be furnished by the parents of the qualified children at the time of admission to JNVs) As per Jawahar Navodaya Vidayalay, Mundali, District-Cuttack, State ODISHA letter No. dated my ward Mast/Kum. has qualified the entrance exam for admission to Class-VI at JNV, Mundali, Dist-Cuttack, State-ODISHA during the session I am residing alongwith my ward mentioned above at following address since. Village : Town : District : State : Pin Code : Certified that the information furnished by me is true and no fact has been concealed. CERTIFICATE (Signature of Parent) Full Name : Address: (To be filled up by the District Authorities and issued under the signature of SDM/Tehsildar to the parents of the child selected for admission to class-vi in JNVs through JNVST-2017) This is to certify that the above information furnished by Shri/Smt. Father/ Mother of Master/Kumari a candidate selected for JNVST-2017 admission to Class-VI in JNV, Mundali, Dist-Cuttack, State-ODISHA has been verified from the records and is found to be correct. The area where residence located falls under (rural/urban) area of District Cuttack. Signature of SDM/ Tehsildar AFFIDAVIT (An affidavit to be furnished by parents on ` 10/- Stamp Paper duly attested by Notary at the time of Admission to Class-VI in JNVs through JNVST) I,, Age years, father/mother of Mast/Kum. Resident of Village Tehsil, Dist- solemnly declare and affirm as under: a. My ward is a student of (Name and complete address of the Institution) located in which is a rural area in District in State since. He has passed Class-V from this Institution during the Session. b. My ward is residing with me at following address which is located in the rural of District. Verified on this the day 20 at that the contents of above affidavit are true to best of my knowledge and belief based on record and believed by me to be true. Signature (DEPONENT) Place Name Date

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