Annexure Al: Student Admission Form

School Name: Form N2:

School Code:

U-DISE Code:
Status: Government Please paste passport
School Admission Number: size (35 mm (w) x 44
tnu
Admission Date: / / mm (H)) colored
Session: photograph with
Type of Admission: New / Re-admission/ Transition white background
If re-Admission, Old Admission N2: here.
Unique SRN (Student Registration Photo should not
Number) generated by MIS: exceed borders.
Enrollment No if allotted by Board: Do NOT staple.
# Please read the following instructions carefully before filling Admission Form.
1. Use CAPITAL letters only.
2. Tick (e.g.l) wherever applicable and strike-off (e.g. Male /ale) whichever not applicable.
3. Fields marked with * are mandatory.
Students/Parents shall fill in the form from section '1. Student Information' onwards
1. Student Information
Class of Admission: Stream(for iith/iP):Arts/Commerce/Science
Name* (as on Aadhaar): Mr/Miss/Mrs
Date of Birth*: / / Gender*:Male/Female
AadhaarN2:
EID N2 (if Aadhaar is not available):
Place of Country*: I . State*: I
1 T 1 I
Birth* District*: I I Tehsil*: I I City/Village*:
Email ID: Mobile N2:
Nationality*: Domicile of Haryana*? Yes/No
2. Parent/Guardian Information
Father's Name (as on Aadhaar)*:
Father's Aadhaar N2: Mobile N2*:
Agriculture (Farmer)/ Laborer/ Self Employed/ Private Job/ Haryana State Govt. Employee/ Other State
Father's Occupation*:
Govt. Employee/ Central Govt. Employee/ Military Personnel/ Para -military Personnel/ PSU Employee
Office Address of Father (if
working):
Father's Highest Education Illiterate / Schooling / 10 Pass / 10+2 Pass / Certificate Holder / Diploma Holder / Bachelor's Degree Holder
Qualification: / Master's Degree Holder / Doctor's Degree Holder
Father's PAN: Income Tax Payee: Yes/No Email ID:
Mother's Name (as on Aadhaar)*:
Mother's Aadhaar N2: Mobile N2*:
House Wife/Agriculture (Farmer)/ Laborer/ Self Employed/ Private Job/ Haryana State Govt. Employee/
Mother's Occupation*: Other State Govt. Employee/ Central Govt. Employee/ Military Personnel/ Para-military Personnel/ PSU
Employee

M ice Address of Mother (if

working):
Mother's Highest Education Illiterate / Schooling / 10 Pass / 10+2 Pass / Certificate Holder / Diploma Holder / Bachelor's Degree Holder
Qualification: / Master's Degree Holder / Doctor's Degree Holder
Mother's PAN: Income Tax Payee: Yes/No Email ID:
Whether, Parents engaged in 'Unclean Occupation'? Yes / No
Parents Annual Income*: (in Rs.)
Student belongs to 'Below Poverty Line° (BPL) family*? Yes / No
Issued Date: / /
If 'Yes': BPL Certificate N2: Issuing Authority:

3. Information of Siblings studying in this School (mandatory if student has sibling, mention details of siblings)
1stSibling's Full Name: Class:
Student Registration Number of Sibling (SRN): Relation: Brother / Sister
2ndSibling's Full Name: Class:
Student Registration Number of Sibling (SRN): Relation: Brother / Sister
4. Student's Address Information
Correspondence Address*: Distance from School (KMs)*:
 City/Village/Town*: Tehsil*: Block:
Area of living Rural / Urban
District*: State*: PIN*:

Landline Number: STD: Phone:

Is 'Permanent Address' same as Correspondence Address?* Yes/No (If No, fill in Permanent Address details below)
Permanent Address*:

City/Village/Town*: Tehsil*: Block:

Area of living Rural / Urban
District*: State*: PIN*:
5. Reservation Information
Religion*: Hindu/ Muslim/ Christian/ Jain/ Sikhs/ Parsi/ Buddhist
Category*: General / SC / SBC / BC-A / BC-B / ST Caste (if Reserved Category) :
If Reserved Category : Certificate N2: Issuing Authority:
Issued Date: / /
Physically Handicapped? Yes/No
0 Blindness 0 Low-vision 1 0 Hearing Disability F. 0 Speech Disability 1 0 Loco motor Disability
(Ify,
estype)
Percentage (%)->
Mentally Challenged? Yes/No
1 0 Mental Retardation 1 0 Learning Disability 1 0 Cerebral Palsy
(If yes, type) 1 0 Autism
Percentage (%)4
0Color Blindness / 0 Haemophilia / 0 Deletion syndrome / 0Angelman syndrome / 0Canavan disease /
❑ Charcot—Marie—
Genetic Tooth disease / ❑ Cri du chat / 0 Cystic fibrosis / 0
Down syndrome / ODuchenne muscular dystrophy / 0Haemochromatosis /
Disorder: 0Klinefelter syndrome / ❑ Neurofibromatosis / ❑ Phenylketonuria / 0 Polycystic kidney disease / 0Prader—Willi syndrome /
0
Sickle-cell disease / 0 Tay—Sachs disease / 0 Turner syndrome
6. Medium of Instruction*: Hindi / English
Compulsory & Optional Subjects taken for class being admitted (for classes VI to XII only)
Compulsory Subjects:

a. b. c. d.
Optional Subjects:
e. f. g. h.
7. Past School Information: (Applicable to students who already have Student Registration N2 and getting Re
-Admitted in this school)
Student Registration Number (SRN, if
available):
Name of Previous School:
School code:
Last class attended: Date of leaving:
/ / % Marks/Grade Obtained:
8. Student's Bank Account Information (Mandatory if student already has a bank account)
Account Holder Name / Joint Account Holder Name (if any):
Relation of Joint account holder with student: Mother / Father / Brother / Sister / Grand-Father / Grand-Mother / Aunt / Uncle
A/c N2: IFSC Code:
Bank Name: Branch Name & Code:
9. Other Information
Student's Hobbies:
Student's Past Achievements
(SPAT/Sports/Scholarships):
10. Declaration by Parent/Guardian*

I hereby declare that all the information given here is true. I take full responsibility of my child to behave sincerely. We will abide
by all the rules and regulation of the institution. Please admit my child in class
Place:
Date:
Signatures of the Parent/Guardian
11. Attached Documents and Certificates Section:
1. 2.
3. 4.
5. 6.
For Office Use Only
Permission granted to admit in class:

Signatures of Head of Institution

DEO BEO (with Full name and Seal)
Note: Parents/Student may retain photocopy of completely filled in admission form for future reference.