4.Admission FORM for Class XI 2015

DURGAPUR
Application Form For Provisional Admission To Class XI(Eleven) in the Academic Year 2015-2016
NO. HSMS/2015-16/A_____
For office use only
Admission No.: AISSCE/
Date:
2
0
1
4
PLEASE AFFIX HERE
LATEST POST CARD SIZE (LANDSCAPE)
COLOURED PHOTOGRAPH
OF STUDENT WITH PARENTS
__________________________
Principal's Signature
1. STUDENT'S NAME IN FULL (BLOCK LETTERS)
NAME
SURNAME
2. A) DATE OF BIRTH (IN FIGURES)
Boy/Girl
B) DATE OF BIRTH (IN WORDS)
Date
C) PLACE OF BIRTH
Month
Year
____________________________________________________________
3. ADDRESS FOR CORRESPONDENCE
_______________________________________________________________
_______________________________________________________________
PHONE
Residence _______________ Office: ______________Mobile: __________________
4. NATIONALITY
_______________________ Mother Tongue________________________
5. DO YOU BELONG TO ST/SC/OBC
____________________________________________________________
6. PARTICULARS OF FAMILY BACKGROUND:
FATHER
MOTHER
NAME (BLOCK LETTERS)
PLACE OF WORK & ORGANISATION
SAIL/NON SAIL *
DESIGNATION
ACADEMIC QUALIFICATION
OFFICE ADDRESS
E-MAIL ID
OFFICE
PHONE:
RESIDENCE
MOBILE
7. SCHOOL LAST ATTENDED
Board of Affiliation
____________________________________________________________
____________________________________________________________
8. INTEREST IN CO-CURRICULAR ACTIVITIES ____________________________________________________________
* SAIL- STEEL AUTHORITY OF INDIA LIMITED
P.T.O.
9. MARKS/GRADES OBTAINED IN PREVIOUS EXAMINATIONS IN PERCENTAGE
CLASS –X
CLASS IX
ST
1 TERM
(Grade/Marks
Out of 100)
SL NO.
SUBJECT
1.
2.
3.
4.
5.
6.
7.
English
Mathematics
Physics
Chemistry
Biology
Science (for CBSE students)
Total
ND
RD
2 TERM
(Grade/Marks
Out of 100)
ST
3 TERM
(Grade/Marks
Out of 100)
AVERAGE
ND
1 TERM
2 TERM
PRE-BOARD
(Grade/Marks (Grade/Marks (Grade/Marks
Out of 100)
Out of 100)
Out of 100)
AVERAGE
10A. ELECTIVE SUBJECTS FOR CLASS XI (SCIENCE STREAM)
1. ENGLISH (CORE)
2. PHYSICS
3.
CHEMISTRY
4.
MATHEMATICS
AND ANY ONE OF THE FOLLOWING: BIOLOGY & COMPUTER SCIENCE. (PLEASE INDICATE YOUR CHOICE BELOW).
5. _____________________________________________ 6. (OPTIONAL) PHYSICAL EDUCATION
10B. ELECTIVE SUBJECTS FOR CLASS XI (COMMERCE STREAM)
1. ENGLISH (CORE)
2. ACCOUNTANCY
3. BUSINESS STUDIES
4. ECONOMICS
AND ANY ONE OF THE FOLLOWING: MULTIMEDIA & WEB TECHNOLOGY, MATHEMATICS &
ENTREPRENEURSHIP (PLEASE INDICATE YOUR CHOICE BELOW).
5. ____________________________________
6. (OPTIONAL) PHYSICAL EDUCATION
10C. ELECTIVE SUBJECTS FOR CLASS XI (HUMANITIES)
1. ENGLISH (CORE)
AND ANY FOUR OF THE FOLLOWING: GEOGRAPHY, ECONOMICS, POLITICAL SCIENCE, MATHEMATICS, HISTORY,
MULTIMEDIA & WEB TECHNOLOGY, FINE ARTS (PLEASE INDICATE YOUR CHOICE BELOW).
2. _____________________, 3. ______________________, 4. ____________________, 5. ____________________
6. (OPTIONAL) PHYSICAL EDUCATION
11.
CAREER OPTION: (I) ENGINEERING, (II) MEDICAL, (III) CA, (IV) ICWA, (V) LAW, (VI) BASIC SCIENCE
(VII) PROFESSOR/TEACHER, (VIII)JOURNALISM, (IX) GOVT./BANK OFFICERS
ANNUAL INCOME OF THE PARENTS E. ___________________________________________
12.
13.
IS ANY OF YOUR BROTHER OR SISTER STUDYING IN HSMS, DURGAPUR ? IF YES, GIVE THE FOLLOWING DETAILS:
SERIAL NO.
NAME
CLASS & SECTION
ADMN.NO.
YEAR OF ADMN
1.
2.
14. ENCLOSURES: PHOTOCOPIES OF BIRTH CERTIFICATE & MARK SHEETS OF CLASS IX & X ATTESTED BY THE
RESPECTIVE SCHOOL PRINCIPAL.
DECLARATION
a)
b)
c)
d)
e)
I fully understand that the school, on accepting the application for admission, is not in any way bound to grant admission, as
admission is purely based on the availability of seats. I also understand that the decision of the Admission Committee regarding
admission will be final and binding on me.
In the event of my ward's selection for admission, I shall have no objections to the instructions and guidelines of the school. I further
undertake to abide by all the school rules as may be put into effect from time to time.
This admission is purely provisional and will be confirmed on production of the certificates listed below in June, 2015 and subject to
acceptance of the candidature by CBSE.
The name of the student will be struck off from the roll and money paid will not be refunded if the student remains absent without
intimation for a week.
The information given above are true to the best of our knowledge.
NOTE: ANY WRONG INFORMATION / DATA WILL BE SERIOUSLY DEALT WITH.
Place: ____________
Date: _____________
_________________________
Signature of student
__________________________
Signature of Father
_____________________
Signature of Mother
th
The following certificates are to be submitted by 30 June, 2015 or else the provisional admission will be cancelled.
1.
3.
Attested copy of Mark Sheet of Class-X (Two Copies), 2. Attested copy of Pass Certificate of Class-X ( Two Copies )
Migration Certificate in Original. 4. Transfer Certificate/School Leaving Certificate in Original. 5. Character Certificate in Original
from the School last attended.