'- STUDENTADMISSION FORM

School Name : FORM NO,:

School Code :

U-DISE Code :

Status : Government /Government Aided /Private

Pleose Poste Possport
School Admission Number :
Size (35 mm (w) x44
Admission Date:
mm (H) colored photogroph
Session :
with bockground
Type of Admission : New / Re-admission/Transition here
lf Re-Admission, Old Admission No.: Photo should not
exceed borders,
Unique SRN (Student Registration
DO NOT Stople
Number) generated by MIS :

Enrollment No. if allotted by Board :

For gth to 12th Classes Only

# Please reod the following instruction carefully before filling Admission Jorm :
1.Use CAPITAL letters only.
2.Tick (e.g. (/) wherever applicable and strike-off (e.g. Male /fsrs€l€; whichever not applicable)
3.Fields marked with * are mandatory.

Students/Parents shall fill in the form Section '1. Students information'onwards

1. Studentslnformation
Class of Admission :
I Stream (for11th/ 12th )Arts/Commerce/Science
Name * (as on AAdhaar) Mr./Miss/Mrs.
Date of Birth* I Gender * Male /Female
Aadhar No. :

EID No. (if Aadhaar is not available)

Place of Cou ntry* State * I District*

Birth Tehsil * City/Vilage*
EmaillD Mobile No.:
Nationality* : Domicileof Haryana*? lYes/No
2, Parent/Guardianlnformation
Father's Name (as on Aadhaar)*
Father's Aadhaar No. Mobile No.*
Father's Occupation* Agricultu re rmer) /Laborer /Self Em ployed /Private Job /Haryana State Govt. Employee/Other State Govt.
( Fa

Employee/Central Govt. Employee/Military Personnel/ Para-military Personnel/PSU Employee.

Office Address of Father

(if working)

Father's Highest Education llliterate/Schooling/10th Pass/10+2 Pass/Certficate Holder/Diploma Holder/Bachelor's Degree Holder/Master's
Degree Holder/Doctor's Degree Holder

Father's PAN : I lncome Tax Payee : Yes/No. I

EmaillD:
Mother's Name (as on Aadhaar)* : Mobile No.*
Mother's Occupation* House Wife Agricultu re (Farmer) /La borer /Self Em ployed /Private Job /Haryana State Govt. Em ployee
/Other State Govt.Em ployee/Central Govt. Em ployee/M ilitary Person nel/ Para-milita ry PersonnellPSU Em ployee.

Office Address of Mother

(if working)

Mother's Highest Education llliterate/Schooling/10th Pass/10+2 Pass/Certficate Holder/Diploma Holder/Bachelor's Degree Holder/Master's
Qualification : Degree Holder/Doctor's Degree Holder

Mother's PAN: lncomeTaxPayee:Yes/No. I I EmaillD:

Whether, Parents engaged in 'Unclean Occupation'? Yes/No.
ParentAnnual lncome (in Rs.)
Student belongs to 'Below Poverty Line' (BPL) family* ? Yes/No.
lf 'Yes' : BPL Certificate No. : lssuing Authority lssuedDate: I I I
3, lnformation of Siblings studying in this School (mandato ry if student has sibling, me ntio n deta ils of siblings)

1st Sibling's Full Name : Class:

Student Registration N umber of Sibling (SRN) : Relation: Brother/Sister

2nd Sibling's Full Name: Class :

Student Registration Numberof Sibling (SRN) : Relation: Brother/Sister

4, Student's Address lnformation :

Correspondence Address* Distance from School (KM)* :

City/Vlllage/Town*: I tehsil* Block*

Area of living Rural/Urban
X
District* State* : PIN
Landline Nrimber: STD : Phone:
is'Permanent Address'same as correspondence Address ? Yes /No (lf No, fill in Permanent Address details below)
PermanentAddress:

City/Vlllage/Town * Tehsil* Block*

Area of Iivins Rural/Urban
District* State* PIN*

5. Reservationlnfomation
Religion* Hindu /Muslim/christian /iain/Sikhs/Parsi/Buddhist

Category* : General SC/SBC/BC-A/BC-B/ST I Caste(ifReservedCategory): I

if Reserved Category : Certificate No. : issuing Authority : lssued Date: /

Physically Handicapped ? Yes/No.
E Blindness E Low-vision E Hearing Disability il Speech Disability n Loco motor Disabiiity
(lfYes, type)
Percentage (%) )
Mentlly Challenged ? Yes/No.
fl Mental Retardation E Learning Disabilitt E Cerebral Palsy E Autism
(ifYes, Type)

Percentage (76) )
Genetic fl Color Blindness/ tr Haemophilla / n Deletion syndrome / fl Angelman syndrome/ [ Canavan diseasel E Charcot-Marie-Tooth disease/

Disorder: tr Cri Du Chat/ tr Cysticfibrosis / E Down Sybdrome/ E Duchenne muscular dystrophy/ E Haemochromatosis/ E Klinefeltersyndrome/
nNeurofibromatosis/!Phenylketonuria/EPolycystickidneydisease/nPrader-Willisyndrome/ESickle-celldisease/
E Tay-Sachs disease/ [ Turner sybdrome.

6. Medium of lnstruction* : Hindi/ English

Compulsory & Optional Subject taken for class being admitted (for classes Vl th Xll only)
Compuisory Subjects :

a. b. c. d

Optional Subjects:
t h.

7 , Past School lnformation : (Applica ble to stude nts who already have stu dent Registration N o. a nd getting Re-Ad mitted in this school)

5tudent Registration Number

(SRN, if available:)

Name of Previous School : Schooi Code

Last Class aitended : Dateofleaving I I I % Marksr'Grade Obtained :

8. Student's Bank Account lnformation (Mandatory if student already has a bank account)
Account Holder Name / Joint Account Holder Name (if any ) :

Relationofiointaccountholderwithstudent:Mothery'Father/Brother/Sister/Grand-Father/Grand-Mother./Aunt/Uncle
Aic. No iFSCCode:

Bank Name : Branch Name & Code :

9. Other lnformation
Student's Hobbies:
Student's Past Achievement
(SPAT/Sports/Scholarsh i ps) :

10. Declaration by Parent /Guardian*

I hereby declare that all the information given here is true. ltake full responsibility of my child to behave sincerely. We will abide by allthe
rules and regulation of the institution. Please admit my child in class __
Place:
Date: Signature of the Parent/Gua rdian

11. Attached Documents and Certificates Section :

1.. 2

3. 4

5. 6.

FOR OFFICE USE ONLY

Permission granted to admit in Class :

Signature of Head lnstitution

DEO BEO (with full name and seal)

Note : Parents /Student may retain photocopy of completelyfilled in admisson form forfuture reference