| '* State Council of educational R.."r."h "od

T."ining,ChhtAPPLICATION FORM

State Level - NATIONAL TALENT SEARCH EXAMINATION (NTSE) zotT-2018the Students in Class

gm sntiEcSubject ' inlanguage . Textcross (x) any one

ENGLISHHTNDI

(Write In Capital)

1- Candidate's Name(Do not Write Miss/Mister)2- Father's Name (Do not Write DrlPro/lr4r)3- Mother's Name (Do not Write Dr./ProflMrs)

Write Crass [X] only one of the appropriate box 4,5,6,7,10, I land 2l

Date of BirthDate Month Year Study in Class

4- Sex

Male IFemale 2

5- Residential AreaRural I

Urban 2

6- Cast category

UWOBC ISC2

ST3

7- Disability 5121us5/ffirrdT 6r *Ef{Orthopedic/erfur*ftn r

Hearing Impaired/rrov-+rBe z

Visually Impaired/gffia s

Blind/gffii +*Attach certificates if you belong to SC/ST and Sr. No. 7

8- Postal address for correspondence : (DonotFather's and yourName)

Pin Code

10- Type of School in which at class XGovernment/ qrRrq,tq r

Local Body,z ilrftq ftolq z

9- Name & address of School in which studying at VIII level

Pin Code

ll- School located

*For lilling in boxes in Sr. No. 12 to 16 see Code No. Mentioned below -12- Medium of examination -13- Father's educationl5-Mother's education

State Level

17-No. of family members living home

Private aided ,zervn. eEErr crw 3

Private Unaided/eivn. .1-r erg<rr nw 4

Rural/qrfrur r

Urban,zc6fr z

(B) NCERT Level

l9- No. of Sister

More than 5,00,000 (5)21- Parental annual lncome: Up to 50,000 (l)50,001 to 1,00,000 (2)

22- Mobile No.

14- Father's occupation16- Mother's occupation18- No. of Brothers

1,00,001 to 2,00,000 (3)2,00,001 to 5,00,000 (4)E-mailaddress

20-At what number is the candidate among his/her brother and sister (qT{. srri d cfrefleff 6r Fq

To be filled in by the Head of the Institution..... Son/Daughter of Shri/Smt.Certified thatl.Mister/Miss is regular student

of Class X in this SchooUlnstitution and He/She has secured Vo mark in the class IX annual examination, i.e. when

marks out of ... ...he/she was promoted from class IX to class X. He/She has

2. The particulars given by him/her in the application from have been verified and found in order.

3. Mister/Miss ............ Belongs to scheduled casUscheduled tribe category as per the records maintained in

Institution (To be filed for SC/St candidates only) .

DateSignature of the Head Master/Head Mistress/

Gazette Officer With Seal

Last date -31 2017 Exam Date -05 Nov:2017ln

- Space for thePhotogiaph .

passporlsize Black. { White

photographs

should be

endodeO by Head

Roll No.State Code Year Dist. Code Centre Code Serial number

J J I 7

Signature of Candidate Signature ofParents

Codins PlanRead instruction carefully before filing up the Application Form-l- use only Blue or Black Ball point pen WRITE IN CAPITAL LETTRRS Do not mark or write outside the box.

2- Crass[xl only one of the appropriate boxes in items4,5,6,7,l0,ll and2l.

3- Please write code number in items nos.l2rl3rl4,lSand16 as given overleaf.

4- It is the responsibility of the candidate and principal./Head of the school to deposit the filled in fom with the Stateconcerned officer before the last date No request for condemning delay in submission will be entertained whether it is dueto the fault on the Headmaster/Principal of has/her institution .

5- Incomplite or defensive applications or liable to the rejected.

Code No. to be fill in boxes Sr.No. 12 to 16

MEDIUM OF EXAMINATION English-13, Hindi-15EDUCATIN OF FATHER OR MOTHER CodeUpto Primary

Upper PrimarySecondary

Senior Secondary

Graduation

Post Graduation

Doctoral

PfOfeSSiOnal Degfee @nginuing, Mcdicine, McA. MBA Lowest)

Any other

I OCCUPATION OF FATHER OR MOTHER Code2 Professional, Technical and Related Worker

Administative, Executive and Managerial WorkerClerical& Related WorkerSales/Service WorkerFarmer/ Fisher maim & Related WorkerProduction & Related Worker, transportSemi Skilled laborer WorkerNot employed

Ij

24

5 46

5

7 68 7

9 8

[Referto item no.l0]Government A Government School completely financed by the Government.Local Body A local body school is that which is run by Panchayat Raj and local body institution such as Zilapanchyat,

Municipal corporation municipal committee notified area committee and cantonment Board.Private Aided A Private aided school is that which is run by an individual or private Organization and receives Grant from

Government or local body.Private Unaided A Private Unaided school is that which is managed by an individual or a private organization and does not

, receives any Grant from Government or local body.

ur

ADMISSIOM CARI) -Space for thePhotograph passportsize Black & White

photographs shouldbe endorsed by

Head

te un Educa rch and nrnlr=q wtq rr$q gfu,Tr drq qtmr NrsE) 2017-2018

(State Level - NATIONAL TALENT SEARCH EXAMINATroN-2O17-2018)

Date of Examination (qfrHT ftf$) -os fft'kt-r-2017dq gm orrqEd

Roll No.

Centre of Examination

Candidate's Name(Do not Write Miss/Ir4ister)

Father's Name(Do not Write Dr/Pro/lr4r.)

Mother's Name

Of (School) Name(Do not Write Dr./ProflMrs.)

Of District Name

r

Full Postal Address :

Scrutinized By(Office Staff)

Oflice seal

Signature of the Head of the School(With Office Seal)

Signature of Liaison Officer/District LevelOfficer/Authorized for State Level Examination

SAT

Signature of the Invigilator Signature of the candidate in theAt the examination centre presence of the Invigilator Language Test

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J J I 7

f-ryL.-llirffiart State Council of educational Research and Training rChhattisgarh rRaipur

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