| '* State Council of educational R.."r."h "od
T."ining,ChhtAPPLICATION FORM
State Level - NATIONAL TALENT SEARCH EXAMINATION (NTSE) zotT-2018the Students in Class
gm sntiEcSubject ' inlanguage . Textcross (x) any one
ENGLISHHTNDI
(Write In Capital)
1- Candidate's Name(Do not Write Miss/Mister)2- Father's Name (Do not Write DrlPro/lr4r)3- Mother's Name (Do not Write Dr./ProflMrs)
Write Crass [X] only one of the appropriate box 4,5,6,7,10, I land 2l
Date of BirthDate Month Year Study in Class
4- Sex
Male IFemale 2
5- Residential AreaRural I
Urban 2
6- Cast category
UWOBC ISC2
ST3
7- Disability 5121us5/ffirrdT 6r *Ef{Orthopedic/erfur*ftn r
Hearing Impaired/rrov-+rBe z
Visually Impaired/gffia s
Blind/gffii +*Attach certificates if you belong to SC/ST and Sr. No. 7
8- Postal address for correspondence : (DonotFather's and yourName)
Pin Code
10- Type of School in which at class XGovernment/ qrRrq,tq r
Local Body,z ilrftq ftolq z
9- Name & address of School in which studying at VIII level
Pin Code
ll- School located
*For lilling in boxes in Sr. No. 12 to 16 see Code No. Mentioned below -12- Medium of examination -13- Father's educationl5-Mother's education
State Level
17-No. of family members living home
Private aided ,zervn. eEErr crw 3
Private Unaided/eivn. .1-r erg<rr nw 4
Rural/qrfrur r
Urban,zc6fr z
(B) NCERT Level
l9- No. of Sister
More than 5,00,000 (5)21- Parental annual lncome: Up to 50,000 (l)50,001 to 1,00,000 (2)
22- Mobile No.
14- Father's occupation16- Mother's occupation18- No. of Brothers
1,00,001 to 2,00,000 (3)2,00,001 to 5,00,000 (4)E-mailaddress
20-At what number is the candidate among his/her brother and sister (qT{. srri d cfrefleff 6r Fq
To be filled in by the Head of the Institution..... Son/Daughter of Shri/Smt.Certified thatl.Mister/Miss is regular student
of Class X in this SchooUlnstitution and He/She has secured Vo mark in the class IX annual examination, i.e. when
marks out of ... ...he/she was promoted from class IX to class X. He/She has
2. The particulars given by him/her in the application from have been verified and found in order.
3. Mister/Miss ............ Belongs to scheduled casUscheduled tribe category as per the records maintained in
Institution (To be filed for SC/St candidates only) .
DateSignature of the Head Master/Head Mistress/
Gazette Officer With Seal
Last date -31 2017 Exam Date -05 Nov:2017ln
- Space for thePhotogiaph .
passporlsize Black. { White
photographs
should be
endodeO by Head
Roll No.State Code Year Dist. Code Centre Code Serial number
J J I 7
Signature of Candidate Signature ofParents
Codins PlanRead instruction carefully before filing up the Application Form-l- use only Blue or Black Ball point pen WRITE IN CAPITAL LETTRRS Do not mark or write outside the box.
2- Crass[xl only one of the appropriate boxes in items4,5,6,7,l0,ll and2l.
3- Please write code number in items nos.l2rl3rl4,lSand16 as given overleaf.
4- It is the responsibility of the candidate and principal./Head of the school to deposit the filled in fom with the Stateconcerned officer before the last date No request for condemning delay in submission will be entertained whether it is dueto the fault on the Headmaster/Principal of has/her institution .
5- Incomplite or defensive applications or liable to the rejected.
Code No. to be fill in boxes Sr.No. 12 to 16
MEDIUM OF EXAMINATION English-13, Hindi-15EDUCATIN OF FATHER OR MOTHER CodeUpto Primary
Upper PrimarySecondary
Senior Secondary
Graduation
Post Graduation
Doctoral
PfOfeSSiOnal Degfee @nginuing, Mcdicine, McA. MBA Lowest)
Any other
I OCCUPATION OF FATHER OR MOTHER Code2 Professional, Technical and Related Worker
Administative, Executive and Managerial WorkerClerical& Related WorkerSales/Service WorkerFarmer/ Fisher maim & Related WorkerProduction & Related Worker, transportSemi Skilled laborer WorkerNot employed
Ij
24
5 46
5
7 68 7
9 8
[Referto item no.l0]Government A Government School completely financed by the Government.Local Body A local body school is that which is run by Panchayat Raj and local body institution such as Zilapanchyat,
Municipal corporation municipal committee notified area committee and cantonment Board.Private Aided A Private aided school is that which is run by an individual or private Organization and receives Grant from
Government or local body.Private Unaided A Private Unaided school is that which is managed by an individual or a private organization and does not
, receives any Grant from Government or local body.
ur
ADMISSIOM CARI) -Space for thePhotograph passportsize Black & White
photographs shouldbe endorsed by
Head
te un Educa rch and nrnlr=q wtq rr$q gfu,Tr drq qtmr NrsE) 2017-2018
(State Level - NATIONAL TALENT SEARCH EXAMINATroN-2O17-2018)
Date of Examination (qfrHT ftf$) -os fft'kt-r-2017dq gm orrqEd
Roll No.
Centre of Examination
Candidate's Name(Do not Write Miss/Ir4ister)
Father's Name(Do not Write Dr/Pro/lr4r.)
Mother's Name
Of (School) Name(Do not Write Dr./ProflMrs.)
Of District Name
r
Full Postal Address :
Scrutinized By(Office Staff)
Oflice seal
Signature of the Head of the School(With Office Seal)
Signature of Liaison Officer/District LevelOfficer/Authorized for State Level Examination
SAT
Signature of the Invigilator Signature of the candidate in theAt the examination centre presence of the Invigilator Language Test
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State Code Year Dist.Code CentreCode
Serial number
J J I 7