JAWAHAR NAVODAYA VIDYALAYA, MUNDALI, DIST-CUTTACK (ORISSA)-754 006 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 :

_______________________________________________________________________________

__________________________________ PIN________________ Tele No _________________

11. Permanent Address :

________________________________________________________________________________

________________________________PIN ________________ Tele No ______________________

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)

PASTE PASSPORT

SIZE

PHOTOGRAPH OF

CANDIDATE

JAWAHAR NAVODAYA VIDYALAYA, MUNDALI, CUTTACK (ORISSA)-754 006

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 _____________

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 3rd, 4th & 5th

Sl No Particulars CLASS

III IV V

1. (a) Month & year of Admission

(b) Month & Year of Passing

2. (a) Name of the School

(b) Name of VILLAGE & TOWN

where school is situated

At_______________

PO______________

PS______________

Dist_____________

PIN_____________

At_______________

PO______________

PS______________

Dist_____________

PIN_____________

At_______________

PO______________

PS______________

Dist_____________

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)

PASTE

RECENT

PASSPORT

SIZE

PHOTOGRAPH

OF THE

CANDIDATE

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)

Name of Headmaster __________________

N.B.:- THE HEADMASTER OF THE SCHOOL IS

REQUESTED TO VERIFY ALL THE ENTRIES PERSONALLY

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 : ___________________ (Signature of the Father/Guardian)

Name _______________________

PRESENT ADDRESS:-

PERMANENT ADDRESS:

SIGNED IN MY PRESENCE

Signature ________________________

Name____________________________

Date : _______________ PRINCIPAL, JNV, MUNDALI,CUTTACK

(OFFICE SEAL)

JAWAHAR NAVODAYA VIDYALAYA, MUNDALI, CUTTACK (ODISHA)

SOCIO ECONOMIC DATA

FOR OFFICE USE ONLY

Admission No______________ Date of Admission___________________

Category _________________ Sex_______________ Area____________________

(To be filled by the parent / Guardian)

1. Name of the Candidate : _____________________________________

2. Name of :- FATHER : _____________________________________

MOTHER : _____________________________________

3. Date of Birth of student : _____________________________________

4. Address :-

PRESENT ADDRESS PERMANENT ADDRESS

VILL : ________________ VILL : _________________

POST : ________________ POST : _________________

P.S. : ________________ P.S. : _________________

TEH : ________________ TEH : _________________

DIST : ________________ DIST : _________________

STATE: _______________ STATE: ________________

PIN : _______________ PIN : ________________

TELE NO: _____________ TELE NO : ______________

5. Area : RURAL / URBAN 6. SEX - GIRL / BOY

7. Category : GENERAL / O B C / S C / S T

8.

Qualification of Occupation of Yearly Income of

FATHER

MOTHER

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 Father ____________________

Signature of Candidate _______________ Signature of Mother____________________

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

______________________ ________________________ _____________________

______________________ __________________ _____________________

PHOTOGRAPH

OF

FATHER

PHOTOGRAPH

OF

MOTHER

PHOTOGRAPH

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)

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 :____________________________

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

1

2

3

4

9. 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

Signature of Principal with date

Psssport size

photographs of the

Student

PHOTOGRAPH

AFTER THREE

YEARS

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

______________________ ________________________ _____________________

______________________ __________________ _____________________

PHOTOGRAPH

OF

FATHER

PHOTOGRAPH

OF

MOTHER

PHOTOGRAPH

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)

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 :____________________________

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

1

2

3

4

9. 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

Signature of Principal with date

Psssport size

photographs of the

Student

PHOTOGRAPH

AFTER THREE

YEARS

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 1. _______________________________________

8. 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 Test- d) 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)

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

2017-18.

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.

(Signature of Parent)

Full Name : _____________________

Address: _______________________

_______________________________

_______________________________

CERTIFICATE

(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________