APPLICATION FORM
(To be filled in by the Parent/Guardian of the Candidate with the help of the
Headmaster/Headmistress of the School from where the candidate passed
Class V Examination)
1. Name of the Candidate:
Aadhar Number:
PHOTO
of student
2. Sex Male Female TG
3. (a) Category
Gen OBC SC ST
(b Caste :
4. Date of Birth
Date Month Year
Date of Birth in Words :
5. Father’s Name :
6. Mother’s Name :
7. Name of the Guardian and
relationship with him/her, if applicable:
8. School(s) from where the candidate passed Class III, IV and V.
Particulars CLASSES
III IV V
(A) (i) Month & Year of Joining
(ii) Month & Year of Passing
(B) (i) Name of the School
(ii) Is It a recognized school? (YES/NO)
(C) Name of the Village or Town in which
school is located.
(D) Name of the Block
(E) Name of the District
(F) Location of the School Indicate
RURAL/URBAN
(Separate certificate is to be obtained if the candidate had studied classes III, IV & V in
different schools)
CERTIFICATE
(BY PARENT/GUARDIAN OF THE CANDIDATE CONCERNED)
Certified that the information given above is true to the best of my knowledge
and belief. In case, any part of information furnished by me is found incorrect, the
admission of my child/ward may be cancelled. I am ready to produce the relevant
certificates issued by Competent Authorities as and when asked for.
Signature of PARENT/GUARDIAN
Entries verified, certified and found correct.
Signature of the HEADMASTER/HEADMISTRESS
Name:
School Seal :
Desgn.:
(NOTE FOR THE HEAD OF THE SCHOOL: - Following Certificate is required to be
issued in respect of candidate selected for admission in JNV in the respective
district).
CERTIFICATE BY THE HEAD OF THE SCHOOL
Certified that the information given in pages 1 & 2 is found correct as per our
school records. It is also certified that Master/Kumari
was admitted in this School in Class on
(date) and passed Class on
(date).
Signature of the Head of Institution
last studied with School Seal
Date:
UNDERTAKING BY THE PARENT/ GUARDIAN
Certified that the information given in the application form for admission into
Class VI in Jawahar Navodaya Vidyalaya,District: for the academic year
2021-22 for my ward is true to the best of my knowledge and belief. In case any part
of the information furnished by me is found incorrect, admission of my ward may be
cancelled at any time. I am ready to produce relevant certificates issued by the
competent authority to your office when asked in support of entries in my original
application
Signature of the
parent/Guardian
Address of parent/guardian:
Name
Street
Village
Mandal/Block
Pin Code:
STD Code: Phone No
Mobile No:
UNDERTAKING
I, (Father/ Mother/ Guardian) of Kumari/Master
who got selected for admission into Class VI in Jawahar
Navodaya Vidyalaya, ………………District hereby give an undertaking that I am
ready to pay Navodaya Vikas Nidhi from Class-IX to XII every month as per norms of
Navodaya Vidyalaya Samiti.
Signature of the parent/Guardian
Note: This is not applicable to SC/ST categories and all girl students and the parents
whose Income is below poverty line.
UNDERTAKING FOR MIGRATION
(TO BE FILLED BY PARENT IN PRESENCE OF PRINCIPAL, JNV)
I, Father/Mother/Guardian of Kumari/Master
who got selected for admission in Class VI in JNV,
District hereby give an undertaking that I understand that, for promotion
of National Integration and as per the scheme at JNVs, 30% of the students of class IX
from one JNV have to migrate to another JNV from non-Hindi speaking area to Hindi
speaking area and vice-versa and I agree to abide by the rules of NVS in this regard.
Signature of the parent/guardian
Fullname:
Address:
Mobile No:
Land line with STDcode:
MEDICAL FITNESS CERTIFICATE
JAWAHAR NAVODAYA VIDYALAYA
DISTRICT: __________________
01. Name of candidate :
02. Father’sname :
03. Address :
04. Date of birth
05. Height _
06. Weight _
07. Abdomen _
08. Chest _
09. Vision LEFT RIGHT
10 Ears _
11. Throat _
12. Locomotor system _
13. State of vaccination _
14. Skin _
15 Blood Group
16 Dental Hygiene
17. Remarks of Medical Officer : Recommended/not recommended for
admission/Recommended to C.M.O for
Verification if any.
PHOTO OF THE
STUDENT _____________
CIVIL SURGEON
MEDICAL ANTECEDENTS
UNDERTAKING
We, Shri_______________ (father) & Smt.________________ (mother),
the parents of Master/Miss ________________________ , selected
____________________ do hereby declare that our ward doesn’t suffer
from any of the medical ailments listed below.
1. Head Injuries
2. Puo- Intermittent
3. CHD- Congenital Heart Disease
4. AA – Acute appendicitis
5. Epliepsy – Convulsions (Injury, Fever)
6. Blood Disorders (Sickle cell Anemeia, Haemophillia)
7. Communicable Diseases (TB, Hepatitis A & B)
8. Skin Disease.
We further declare that our ward Master/Miss ____________ doesn’t have any previous
medical history which required/still requires prolonged or intermittent periods of medical
confinement either in a hospital/nursing home or in our house.
Certified that the information furnished above is true to the best of our knowledge. Any
wilful suppression or false information on the medical antecedents revealed later, would
make the admission of our ward invalid and liable for actions as deemed fit by the
Vidyalaya and Navodaya Vidyalaya Samiti.
PLACE: FATHER’S SIGN
DATE: NAME:
MOTHER’S SIGN:
NAME:
ADDRESS:
DISABILITY CERTIFICATE
If the candidate is selected under disabled quota he/she should bring the
certificate issued by the competent authority.
CATEGORY/COMMUNITY CERTIFICATE
(OBC/SC/ST)
Category certificate in the prescribed format from the competent authority is
to be submitted by the candidate, wherever necessary.
RURAL AREA CERTIFICATE
(To be issued by the Revenue Officer of concerned Block)
This is to certify that Master/Kumari
Son/Daughter of Shri studied classes
III, IV & V In (Name of the school) of
block and the school is located in the village
Which belongs to rural area of District; ,
State: .
(Signature of the Revenue Officer)
Block:
District.
Office Seal:
Dated:
RESIDENCE CERTIFICATE
(To be furnished by the parents of the qualified children at the time
of admission to JNVs)
As per Jawahar Navodaya Vidyalaya, District ,
State letter No: dated: my ward
Master/Kumari has qualified the entrance exam for admission to
Class VI at JNV, District ,State for the session
2021-22.
I am residing along with my ward mentioned above at the
following address:
Village:
Town:
District:
State:
PinCode:
*The area of residence falls under the Rural /Urban area of the district
Certified that the information furnished by me is true and no fact has
been concealed.
Signature of the parent
Full name:
Address:
*Applicable for the students who seek admission through the studies in NIOS.
CERTIFICATE
(TO BE FILLED UP BY THE DISTRICT AUTHORITIES AND ISSUED UNDER THE SIGNATURE OF
TEHSILDAR TO THE PARENTS OF THE CHILD SELECTED FOR ADMISSION TO CLASS VI IN
JNVS THROUGH JNVST)
This is to certify that the above information furnished by
Shri/Smt Father/Mother of Master/Kumari __
a candidate for admission to class VI in JNV,District has been verified
from the records and is found to be correct.
*The area where residence is located falls under (Rural/Urban) area of the
district .
Signature of Tehsildar
(With Seal)
*Applicable for the students who seek admission through the studies in NIOS.
