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.