[Jawahar Navodaya Vidyalaya, Birauli, Distt.- Samastipur, Bihar (848113)] / Page No. : 01

B I O – D A T A

  1. Name of Student :
  1. Sex:(Male /Female)
  2. (a) Category:(Gen/OBC/SC/ST)

(b) Cast:

  1. Date of Birth :

Date :……………Month :………….…………Year :………………(In digit)

  1. Father’s Name : In English :………………………………………………………………………….

In Hindi :………………………………………………………………………….

  1. Mother’s Name : In English :………………………………………………………………………….

In Hindi :………………………………………………………………………….

  1. Name of the Guardian and his/her relationship with the student in case Father/Mother is not the Guardian :………………………………………………………………………………………………
  2. School(s)from where the candidates passed Class-III & IV and is studying in Class-V.

Class-III / Class-IV / Class-V
(a) / (i)Month and Year of admission
(ii)Month and Year of passing
(b) / (i)Name of the School
(ii) Is the School recognized? [Yes/No]
(c) / Name of the Village/Town in which the School is located
(d) / Name of the Block
(e) / Name of the District
(f) / Whether the School located in Rural/Urban area

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[Jawahar Navodaya Vidyalaya, Birauli, Distt.- Samastipur, Bihar (848113)] / Page No. : 02

C E R T I F I C A T E

(BY PARENT /GUARDIAN OF THE CANDIDATE)

Certified that the information given above is true to the best of my knowledge and belief. In case any information furnished by me is found incorrect/misleading, the admission of my child/ward may be cancelled. I am ready to produce relevant certificates issued by competent authorities as and when asked for.

Date : …………………………..Signature of Parent/Guardian

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

CERTIFICATE BY THE HEAD OF THE SCHOOL

Certified that the information given above is true as per school records. It is also certified thatMaster/Miss………………………………………………………………………………Son/DaughterofShri………………………………………………………………….…...was admitted in this school in …………………………………Class on …………………..…………….(date) and is studying/has passed Class-Vth on ……………………………………………(date).

Signature of the Head

With office stamp

For Office use only

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[Jawahar Navodaya Vidyalaya, Birauli, Distt.- Samastipur, Bihar (848113)] / Page No. : 03

STUDY CERTIFICATE

Certified that Master/Miss…………………………………………………………..Son/Daughter of Shri……………………………………………of Village/Mohalla ……………………………….has studied in Class-III, IV and V in this school w.e.f ………………………………………..…….date to ……………………………… and has been issued transfer certificate on …………………………

Date :……………………………….Signature of Head Master

With Seal

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

STUDY CERTIFICATE

Certified that Master/Miss…………………………………………………………..Son/Daughter of Shri……………………………………………of Village/Mohalla ……………………………….has studied in Class-III, IV and V in this school w.e.f ………………………………………..…….date to ……………………………… and has been issued transfer certificate on …………………………

Date :……………………………….Signature of Head Master

With Seal

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

STUDY CERTIFICATE

Certified that Master/Miss…………………………………………………………..Son/Daughter of Shri……………………………………………of Village/Mohalla ……………………………….has studied in Class-III, IV and V in this school w.e.f ………………………………………..…….date to ……………………………… and has been issued transfer certificate on …………………………

Date :……………………………….Signature of Head Master

With Seal

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[Jawahar Navodaya Vidyalaya, Birauli, Distt.- Samastipur, Bihar (848113)] / Page No. : 04

DECLARATION BY PARENT/GUARDIAN

  1. Name of the Student :……………………………………………………………………………...
  2. Father’s Name :…………………………………………………………………………......
  3. Mother’s Name :……………………………………………………………………………....
  4. Caste (SC/ST/OBC/Gen)…………………………………………………………………...……...
  5. Address (Permanent) :…………………………………………………………………………......

……………………………………………………………………………………………………...Distt.:…………………………..State :………………………….. Pin Code. …………………….

Mobile No. :………………………………………………………………………………………...

  1. Date of Birth :………………………………………………………………………………………
  2. Status of parents : (Central/State/Local Bodies/Gen/Business/Agricultural/Agricultural Labour/Self Employed)

Father :………………………………………………

Mother :………………………………………………

  1. Income of parent per year :

Father :………………………………………………

Mother :………………………………………………

  1. Qualification (Illiterate / Primary /Middle/ Secondary / Inter /Graduation /PG/ Other)

Father :………………………………………………

Mother :………………………………………………

  1. Total No. of family members (Sister/Brother/Father & Mother)

SN / Name of the Member / Relation
1
2
3
4
5
  1. Any disease/illness with which the student has suffered within the last five years.
  2. Whether vegetarian or Non vegetarian (Egg/Meat/Fish)
  3. Any other habit of the student……………………………………..(for example to urinating in the bed).

Date :……………………… Signature of Father/Guardian

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[Jawahar Navodaya Vidyalaya, Birauli, Distt.- Samastipur, Bihar (848113)] / Page No. : 05

U N D E R T A K I N G

I …………………………………………………………………..………….…..….Father/Guardian of Master/Miss………………………………………………………..Class – VI (2017-18) of JNV BirauliDistt.- Samastipur hereby undertake that :

  1. My son/ward is bond to abide all the disciplines, rules & regulation of the Vidyalaya. If he fails to abide by and break any of the rules imposed on him, he will be expelled from the Vidyalaya without assigning any reason thereof.
  2. In case any damage(s) caused by my ward to the Vidyalaya property and articles, whatever the penalty will be imposed upon him/her, I undertake to play the same.
  3. If my son/ward is found involved in the disruption to the distruption of any of the academic or routine activities of the Vidyalaya, he will be expelled from the Vidyalaya without serving any show cause notice to me.

Date :……………………….Signature of Father

Name :

Ward’s/Son’s Name :

Class :

Roll No. :

House

Permanent Address : …………….…………………

………………………………………………………

………………………………………………………

Distt. ………………………… State……………….

Pin Code :……………………. Mb. ………………..

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[Jawahar Navodaya Vidyalaya, Birauli, Distt.- Samastipur, Bihar (848113)] / Page No. : 06

U N D E R T A K I N G

I …………………………………………….Father/Guardian of ………………………………………. Who has been selected for admission in Class –VI(2017-18) to JawaharNavodayaVidyalaya, BirauliDistt.- Samastipur Bihar hereby give the following undertaking. :

  1. That I have read the contents of the information bulletin supplied along with the application, from for admission to the JawaharNavodayaVidyalaya, BirauliDistt.-Samastipur Bihar in respect of my ward and has been explained to me in vernacular and I have understood the same.
  2. I have made a declaration in the application from that in the interest of National Integration and under the provisions of NVS, a student is transferred from one school to another, NavodayaVidyalaya on reaching Clas-IX. I hereby undertake and declare that I shall abide by the said conditions of NavodayaVidyalaya scheme and shall have no objection if my son/daughter/ward is transferred to the NavodayaVidyalaya in any other linguistic state/region as provided in the scheme.
  3. Further I undertake and declare that I shall abide by the aforesaid condition and if my ward/son/daughter refuses to move to stay in any NavodayaVidyalaya, he /she will not be allowed to continue to staying in this Vidyalaya. His/her studies shall be discontinued and I shall withdraw him/her from this Vidyalaya.

Date : ……………………Signature

Name of Father/Guardian

Address:

Principal

JNV Samastipur

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[Jawahar Navodaya Vidyalaya, Birauli, Distt.- Samastipur, Bihar (848113)] / Page No. : 07

ADDRESS CUM VISITOR SHEET

  1. Name of the student :………………………………………………………………………………
  2. JNVST Roll No. :……………………………………………………………………………...
  3. Father’s Name :……………………………………………………………………………...
  4. Mother’s Name :……………………………………………………………………………...
  5. Guardian’s Name :(If Father not alive)...... ……………………………………………………..
  1. Permanent Home Address :………………………………………………………………………..

……………………………………………………………………………………………………...

Distt…………………………….State ………………………Pin Code ………………………......

  1. Correspondence Address :…………………………………………………………………..……..

……………………………………………………………………………………………………...

Distt…………………………….State ………………………Pin Code ………………………......

  1. Name, Address and relationship of the person who will meet the student in the Vidyalaya (two only) in addition to Mother & Father.

SN / Name of Visitor / Address of Visitor / Relationship with student / Photograph of Visitor
1
2

All telegram/letters sent to the students may please be communicated to the above address. Any change in the above address shall be communicated immediately to the Principal, JNV BirauliDistt.-Samastipur, Bihar.

Signature of Father/Guardian

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[Jawahar Navodaya Vidyalaya, Birauli, Distt.- Samastipur, Bihar (848113)] / Page No. : 08

ANNEXURE

It is notified that the Samiti will charge initially Rs. 200/ per students per month (which may gradually increase to Rs. 300/-per month from students of Class-IX and above excluding SCs/STs/Girls and students whose families are below poverty line. The guardian/parents are requested to make up their mind on the issue before taking admission in Class-VI (2017-18).

Signature of the Principal

UNDERTAKING

I……………………………………………………………………………………..………..Father/Guardian of Master/Miss………………………………………………………………JNVST Roll No. …………………….. have gone through the above circular of the SamitiI am ready to pay fee whatever fixed by the Samiti as per rules.

Signature of Father/Guardian

Name of Guardian

Relationship with the Students

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[Jawahar Navodaya Vidyalaya, Birauli, Distt.- Samastipur, Bihar (848113)] / Page No. : 09

JNVST -2017-18

(Rural/Urban Certificate of the School)

It is certified that ……………………………………………………………...………………………….. (Name of the School where the student studied in Class –V) is situated in Rural/Urban (√) area of the Samastipur district.

Signature & Seal of

Date : …………………….B.E.O./B.D.O./C.O.

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[Jawahar Navodaya Vidyalaya, Birauli, Distt.- Samastipur, Bihar (848113)] / Page No. : 10

AFFIDAVIT

An affidavit containing the following declaration in presence of First Class Magistrateby the Father or Guardian (in case father is not alive), is to be submitted to the Vidyalaya at the time of admission.

I……………………………………………………………………………...………..Father/Guardian of Master/Miss…………………………………………………………………Village ………………...….. PO………………………………… PS/Thana………………………..Distt…………………..………… State……………………………… Pin Code …...... who has been selected for admission in JNV, Birauli, Distt-Samstipur Bihar appearing in the JawaharNavoadayaVidyalaya Selection Test-2017-18 in the Samastipur district and no other district of India prior to the present Selection Test.If any part of the above declaration is found incorrect in future the admission of my ward shall be liable for termination with the issue of school leaving certificate from school administration for furnishing such wrong information by me.

Date :……………………….

Place :………………………Signature of Father/Guardian

Name : ……………………….

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[Jawahar Navodaya Vidyalaya, Birauli, Distt.- Samastipur, Bihar (848113)] / Page No. : 11

AFFIDAVIT

(An affidavit to be furnished by parents on Rs. 100/- Stamp Paper duly attested by Notary at the time of admission to Class-VI in JNV through JNVST-2017)

I…………………………………………………………………………, Age ……………………Years Father/Mother of Master/Miss……………………………………………………………..Resident of Village………………………………Tehsil……………..…………Distt………………………solemnly declared and affirm as under.

a) My ward is a student of …………………………………………………………………..... (Name and complete address of the School) located in …………………………………..(Name of place) whichis a Rural/Urban area in District-Samastipur in BiharState since …………………………………..

He/she 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/Urban area of District – Samastipur, Bihar.

Verified on this the …………day…………month….……...year at …………………(Time) that the content of above affidavit are true to the best of my knowledge and belief based on record and believe by me to be true.

Signature

(Deponent)

Name

Place …………………………

Date ………………………….

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[Jawahar Navodaya Vidyalaya, Birauli, Distt.- Samastipur, Bihar (848113)] / Page No. : 12

RESIDENTIAL CERTIFICATE

(To be furnished by the parents of the qualified children at the time of admission to JNVs)

As per JawaharNavodayaVidyalaya, Birauli, District- Samastipur, State – Bihar, Letter No. ……..………………………………….…..……………..dated.………………………….Myward Master/Miss……………………………………………… has qualified the entrance exam for admission to Class-VI at Jawahar Navodaya Vidyalaya, Birauli Distt- Samastipur State-Bihar during the session 2017-18.

I am residing along with ward mentioned above at following address since……………………………

Village……………………………….Town ……………………………Distt…………………………...

State………………………………….Pin Code………………………..

Certified that the information furnished by me is true and no fact has been concealed.

Place ………………………..Signature of Parent

Date ………………………..Full Name

Address

CERTIFICATE

(To be filled by the Districts 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)

This is to certify that above information furnished by Shri/Smt. ……………………………………… Father/Mother of Master/Miss…..…………………………………….…………………. a candidate selected foradmission to Class-VI inJawahar Navodaya Vidyalaya, ……………………………………. Distt………………………………………. has been verified from the records and is found to be correct. The area where residence is located falls under (Rural/Urban) are of district …………………………………

Signature with Seal

SDM/Tehsildar

For Office use only

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[Jawahar Navodaya Vidyalaya, Birauli, Distt.- Samastipur, Bihar (848113)] / Page No. : 13

Information to the furnished by the Headmaster/Principal of School last attended by the candidate.

  1. Name of the Vidyalaya……………………………………………………………………………..
  2. Complete Address …………………………………………………………………………………

……………………………………………………………………………………………………..

  1. Name of the Head Master…………………………………………………………………………
  2. Mobile No./Phone No……………………………………………………………………………..

Details of Student :

  1. Name of Student (i) In Hindi :…………………………………………………………………..

(ii) In English :………………………………………………………….……..

  1. Father’s Name (i) In Hindi :…………………………………………………………….……..

(ii) In English :…………………………………………………………..……..

  1. Mother’s Name (i) In Hindi :……………………………………………………………..……..

(ii) In English :…………………………………………………………..……..

  1. Permanent Address :………………………………………………………………………………

……………………………………………………………………………………………………..

  1. Correspondence Address ……………………………………….…………………………………

……………………………………………………………………………………………………..

  1. Admission No.:……………………………………………… Date :……………………………...
  2. School Leaving Certificate No. :…………………………….Date :……………………………...
  3. Details of Attendance of Students :

Class / No. of Class Conducted / No. of Class Attended by the Student / Percentage
Class-III
Class-IV
Class-V
  1. Performance of Attendance of Student in Final Examination :

Class / Percentage / Grade
Class-III
Class-IV
Class-V
  1. If student was admitted on the basis of T.C. issued by some other school, details there of :
  2. Name of School :……………………………………………………………………………
  3. Address :…………………………………………………………………………………….
  4. TC No. :………………………………………..Date :……………………………………...
  5. Class in which T.C. was issued …………………………………………………………....

Signature of HM with Seal

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[Jawahar Navodaya Vidyalaya, Birauli, Distt.- Samastipur, Bihar (848113)] / Page No. : 14

The candidate will affix recent colored passport size photograph (06 No.) in the box provided below :

Name of the Student : …………………………………

JNVST Roll No. : …………………………………………

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[Jawahar Navodaya Vidyalaya, Birauli, Distt.- Samastipur, Bihar (848113)] / Page No. : 15

HOUSE SHEET

(To be filled by the Student)

  1. Name of the Student :…………………………………………………………………….……….
  2. JNVST Roll No. : ………………………………………………………………………….……….
  3. (a) Father’s Name :…………………………………………………………………….………….

(b) Father’s Occupation:…………………………………………………………………………

4.Mother’s Name :……………………………………………………………………………………

5. Guardian’s Name :…………………………………………………………………………………

6. Addresses :

a. Permanent Home Address :
……………………..…......
…………………….…………………………
………………….……………………………
………….……………Pin …………………. Mobile No. ……………………….…………. / b. Correspondence Address :
……………………..…......
…………………….…………………………
………………….……………………………
………….……………Pin …………………. Mobile No. ……………………….………….

7. Name and relationship of Visitor’s with the student (other than Mother & Father):

SN / Name of Visitor / Relationship with the Student / Photograph
Affix Photograph of Visitor / Affix Photograph of Mother
Affix Photograph of Visitor / Affix Photograph of Father

(To be filled by the Office Staff)

Allotted House ………………………………… Allotted Class ………………….. Section...…………...

LDCJNVST I/CPRINCIPAL

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