1. No category

Modi Public School, Siliguri
A Co-Educational Day cum Residential School
Under the Aegis of Modi Group of Institutions, Kota, Rajasthan
Application No. ........................................ Admission No. ............................
(To be filled in by the office)
NON-TRANSFERABLE
Recent
Passport Size
Coloured
Photograph
(Please fill in BLOCK LETTERS)
1. Name of the pupil : Master / Miss (ümark)
Example
Y A
S
K U M A R
H
Date
Month
A G A R W A L
Year
Example
2. a. Date of birth
2 2
1
2
2
0
0
5
b. Date of birth in words ............................................................................................................
c. Age as on 1st April, 2015............................... years ...................... months .............................
d. Sex
Male
Female
e. Blood Group ...............................................
f. Religion ..................................................... g. Nationality .......................................................
3. Tick the class to which admission is sought
NUR KG
I
II
III
IV
V
VI VII VIII
4. Residential address ..................................................................................................................
...................................................................................................................................................
Phone Nos. Resi .................................................... Office .......................................................
5. Family Particulars :-
FATHER
MOTHER
a. Name ...............................................................
...............................................................
b. Academic Qualification .....................................
...............................................................
c. Occupation ......................................................
...............................................................
d. Designation .....................................................
...............................................................
e. Office Address .................................................
...............................................................
.................................................
...............................................................
g. Mobile No. ......................................................
...............................................................
h. E-mail ID (if any) ....................................................................................................................
I. Specimen signature ..............................................................................................................
(In case of local guardian)
j. Parents’ anniversary ..............................................................................................................
6. a. Name and address of the previous school ...............................................................................
b. Marks obtained in the last annual examination
English
2nd Language
Hindi / Bengali
Maths
Science
Social Science
7. Whether belongs to SC / ST / OBC ......................... Yes / No, if yes please enclose certificate
8. Takes interest in extra curricular activities : Games / Dance / Singing / Craft / Recitation / Others
9. Details of siblings (sister or brother)
I. Name .......................................... Class .............. School ....................................................
ii. Name .......................................... Class .............. School ...................................................
iii. Name ......................................... Class .............. School .....................................................
10. Distance of school from the child’s residence (approx in Km.)......................................................
11. School Bus required Yes / No. (If Yes, please collect seperate Bus form for the Bus Stop).
Signature (Father) .........................................................
Signature (Mother ) .........................................................
INSTRUCTIONS
The Registration Form should reach the school latest by ......................................... Filling up the entire form is mandatory.
Incomplete form may not be considered. The following documents must be attached with this form.
a. Self attested Photocopy of the Birth Certificate of the child.
b. Self attested Photocopy of the Marksheet / Transfer Certificate of the previous school.
c. One recent passport size photograph of the pupil, duly pasted in the application form.
d. Self attested SC / ST / OBC certificate (if any).
FOR OFFICE USE
1. Records verified ............................................................................ Fee paid ................................................................................
2. Recommendations of the admission incharge ................ ..............................................................................................................
3. Principal’s remarks ......................................................................................................................................................................
UNDERTAKING
I, Shri / Smt. ___________________________________Father / Mother / Guardian of
Master/Miss______________________________________ who is seeking admission to Class_________at
Modi Public School Siliguri, give of my own free will and choice, the following undertaking that :
1. I fully understand the admission is purely provisional subject to submission of required documents such as
Marks Statement of previous class passed, Transfer Certificate duly countersigned, Date of Birth
Certificate and Migration Certificate as applicable by within 15 days of the year of admission, failing to
which the provisional admission will stand automatically cancelled.
2. I will not ask for refund of fees paid once to the School, Except Security Deposit without interest, at the time
of withdrawal of my above named ward.
3. I am fully aware of the fact that a minimum of 75% of total attendance is obligatory and my ward is likely to
be debarred from appearing at Annual / C.B.S.E. Examination due to shortage of attendance.
4. My ward will attend classes during school hours regularly. I will invariably give prior information of any long
absence of more than two days to school authorities producing Medical Certificate.
5. I will clear all the school dues up to and including the month of application or the entire session, as
applicable, for the issuance of a Transfer Certificate.
6. I will deposit school fees as per schedule given in the Fee Slip. I understand that I will have to pay Late Fee
for the first month of default along with the fees of the following month and that name of my ward will
automatically be struck off, if I do not pay two month's fee together subject to its restoration only after
payment of re admission fee in addition to all outstanding dues to date.
7. I take full responsibility of good conduct of my ward at the school and give my written consent to accept
without any reservation whatsoever disciplinary action taken by the School authorities in their wisdom
against my ward for indulging in any act of indiscipline or improperiety at school.
8. I promise that my ward will always come properly dressed in neat and clean School uniform and on time.
9
I fully appreciate that satisfactory progress at studies is expected of my ward. He/She will not in any case
be allowed to continue at the School after his/her failure in the same class twice. I will constantly stay in
contact with the School monitoring my ward's progress at studies and also coach/get him/her coached at
home, if needed.
10. I agree to abide by the Rules / Decisions of the School Management framed / taken from time to time. I
know that any breach on my part or that of my ward can lead to his / her being removed from the school
without notice and that the discretion of the School authorities is not challengeable in any court of law or
otherwise.
11. I will not send my child on any motor vechicle without having License or Helmet.
Date :..............................
Signature of Parent / Guardian