(TO BE SUBMITTED AT THE TIME OF SUBMISSION OF CBSE EXAM FEES) TA (77 2015-16) ritiT Exam. Fee Form (Session 2015-16) ftrd-4 (PATRACHAR VIDYALAYA) itur Nmo, 7fttzT Staple Unattested DIRECTORATE OF EDUCATION, GOVT. OF NCT OF DELHI T'T, ft MI-88 (BL-BLOCK, SHALIMAR BAGH, DELHI-88] TfRi4 #R-QTM (Affiliated with CBSE) F fir 1T t4rEi Black & White Photograph with Computerized Name and Date TC/ Class trqr itcwr uft.t. ft-ar6-4 5N1 r-4Trr) P.V. No. (To be given by the Patrachar Vidyalaya) 311771T ftk7T/ (IMPORTANT INSTRUCTIONS uicni Tctrzrr Re i f4--eztf qd,4 4R-citct .crrzr ITO 40I? Please fill the Admission Form after reading the instructions given in the Prospectus. 71 c Tal7 Tt I - 19 TzM 1.0 I I. 31-1T7 f tit ttfT7 c T f4.7 T 721-1ff 146T-41-1 TM R 4 x 3 Paste 4 x 3 cm Size Photograph on the Identity Card and Mark his/her signature in the space provided. Student should fill up the columns in the I-card. f T7T-47rr Trrarrtc& mt 1. ftErt Iiit44-ff f i ft Choose subject carefully. Change of subject is not allowed at a later stage. 311:f4 . TT ftM 1 -#1 I / Choose and write the District where the student resides (North, East, South, West, Central) 2. ft114 TT 7 917/ Name of the Candidate (In CAPITAL LETTERS) 1. fOr41 it7 7 fit 3. 91(11 ti3T 971/ Mother's Name in CAPITAL LETTERS 4. 1ac11t 'T 9T1i/ Father's Name in CAPITAL LETTERS I 5. I I I I -41 it4/ Date of Birth 6. .i 41/ Gender 7. q4/ Category Paste unattested 8. 7TterzTUT/ Nationality Black & White 9. ftT-Ft/T/ Disabled Photograph with 10. IITFIEfT/ Mother Tongue 11. ffli/ Religion Computerized Name and Date 12.3111:111 1:14 71)-71—dT/ Your Previous Qualification 13.fti4/ Subjects u))' TOIT/ Code No. / Medium 14. c > ftZul/ Detail of Fee 1. 2. 1. Exam Fees 3. 4. 2. Additional Subject Fees 5. 6. Additional Subject 3. Total 15. ft-4iff chi TpT 71/ Address of Residence (in CAPITAL LETTERS) ‘1 ■ 3-4/ State Pin Code /ff-i43 741-17/ Telephone No tat-a/Mobile No 16. Email Id 17.TR al cr) 3IPT-4t Parental annual Income Rs. p.a. 18.Only for the candidates of class XI & XII a) Roll No. of Class X passing b) Year c) Name of Board/ University d) Year of class XI passing (if applicable) Note: Attach two Self Attested copies of all the followine documents: For Class XII I) Tenth Class mark sheet 2) Tenth passing certificate (issued by board) 3) Caste certificate/ disability certificate (if applicable) 4) Copy of the Admission Form Receipts For Class X I) Two self attested copies of SLC/Birth certificate 2) Caste Certificate/ Disability Certificate (if applicable) 3) Copy of the Admission Form Receipts ft,rifT/ ( Date faur4 Tirdi—fttii/3ft711c14) ufdTT Signature of the Student