jk"Vªh; eqDr fo|ky;h f'k{kk laLFkkuNATIONAL INSTITUTE OF OPEN SCHOOLING

A-24/25, Institutional Area, Sector-62, NOIDA, U.P.

izos'k ds fy, vkosnu i= 2010-11 / Application Form for Admission 2010-11

lanHkZ la[;k¼ ½tks izR;kf;r laLFkk ¼,vkbZ½ }kjk vkWu&ykbZu iathdj.k ds ckn fn;k tk,xkReference

after the On-line registerationNumber

(to be given by the Accredited Institution )

QkeZ la[;kForm No..................................

MPORTANT INSTRUCTIONS

1. Please fill the Form reading the instructions given atAppendix ‘J’. /

2. Follow these steps: (i) Fill the form but do not sign it yet; (ii) Paste your photograph; (iii) Then sign form and submit of them to theAI (Study Centre). /

(i) (ii) (iii)

3. Use Blue/Black Ball Point Pen Only for filling up the form/

ONLYAFTER

,

d`i;k ifjf'k"V ^ts* ij fn, x, funsZ'kksa dks i<+us ds ckn gh QkWeZ HkjsaA

bu ckrksa dk ikyu djsa QkWeZ Hkjsa fdUrq vHkh gLrk{kj ugha djsa ewy izfr ij QksVks fpidk,¡ QkWeZ ij gLrk{kj djsa vkSj ,vkbZ v/;;u dsUnz ij tek djsaA

QkWeZ Hkjus ds fy, dsoy uhyk@dkyk cky isu dk iz;ksx djsaA

1. Name of Candidate in CAPITAL Letters

2. Father’s Name in CAPITAL Letters

3. Mother’s Name in CAPITAL Letters

4. Guardian's/Institution's Name in CAPITAL Letters for Orphan

5.

Address

6. Date of Birth

fo|kFkhZ dk iwjk uke @

firk dk iwjk uke @

ekrk dk iwjk uke @

vfHkHkkod@laLFkk dk iwjk uke @

i=&O;ogkj@vukFkky; ds fy, irk

tUefrfFk@

@PostalAddress in CAPITALLetters/Orphan Homes

ftyk@

jkT;@ fiu dksM

nwjHkk"k@

District

State Pin Code

E-mail

Telephone

23.

24.

25. Total amount of fee paid

fo"k;ksa dk pquko ¼U;wure rFkk vf/kdre 7] rkfydk&1 ns[ksa½@

ek/;fed ijh{kk

d mÙkh.kZ gksus dk o"kZ ¼[k½ vuqØekad la-

¼x½ cksMZ dk dksM@ ifjf'k"V ^ts* ij fn, x, funsZ'k ds vuqlkj dksM fy[ksaA@

dqy ns; 'kqYd dh jkf'k@

izos'k 'kqYd vfrfjDr fo"k; 'kqYd Vhvkslh 'kqYd dqy 'kqYd

cSad Mªk¶V la-@ cSad Mªk¶V dh frfFk@cSad Mªk¶V tkjh djus okys cSad dk uke o LFkku@

5 Choose Subjects (Minimum 5 and Maximum 7, See table-1)

Admission Fee Additional Subject Fee TOC Fee Total Fee

/

( ) /

Xth Board Exam

(a)Year of Passing /(b) Roll No.

(c) Code of the Board Write the code as per

instruction mentioned at

(a) + + =

(b) Bank Draft No. (c) Date of Bank Draft

(d) Name of the Bank & Place of issuing Bank Draft _____________________________________

Appendix-J.

(e) Unique number of Syndicate/Indian Bank

(If fees paid through Challan)

7. Gender

8. Category

9. Disability

10. Disadvantaged

Group

10a. Orphan

11.

Course Applied

for

12. Medium

of Study

fyax @

oxZ @

fodykaxrk @

oafpr oxZ@

vukFk@

ikB~;Øe ftlds fy, vkosnufd;k gS@

vè;;u dk ek/;e@

13.

Mother Tongue

14. Nationality

15. Religion

16. Your

Previous Qualification

17.

Father's Edu.

Qualification

18.

Mother's Edu.

Qualification

ekr`Hkk"kk

jk"Vªh;rk @

/keZ@

vkidh iwoZ ;ksX;rk@

firk dh 'kSf{kd ;ksX;rk

ekrk dh 'kSf{kd ;ksX;rk

19.

Place of Residence

20.

21a. Employment

22.

Annual family income

22a.

jgus dk LFkku

vkidk HkkSxksfyd {ks=

jkstxkj@

vU; ikB~; lgxkeh fØ;k,a

ifjokj dh okf"kZd vk;

vkfFkZd :i ls fiNM+hJs.kh@

Your Geographical Area

21b.

Extra curricular activities

Economically

Backward Class

;gk¡ viuk 4 3 lsehvkdkj dk QksVks fpidk,¡Afiu vFkok LVsiyj dk

iz;ksx u djsaA

X

PASTE HEREPHOTOGRAPH OFTHE STUDENT OF

4 x 3cmIN THIS BOX ONLY

DO NOT USE PIN ORSTAPLER.

fo|kFkhZ ds gLrk{kjSignature of the Student

;gk¡ ls eksM+sa@FOLD FROM HERE

26. D;k vki ØsfMV LFkkukUrj.k ds fy, vkosnu dj jgs gSa(TOC) Whether you are applying for Transfer of Credit/

27.

28. mÙkh.kZ fd, x, fo"k;ksa dk fooj.k ftuds ØsfMV LFkkukarj.k pkgrs gSa @

ek= jk"Vªh; eqDr fo|ky;h f'k{kk laLFkku lhch,lbZ@lhvkbZ,llhbZ@jkT; eqDr fo|ky;@Hkkx 2-6 esa fn, x, jkT; f'k{kk cksMZ ds iwoZ fo|kfFkZ;ksa ds fy,/

For Ex-Students of NIOS /CBSE /CISCE /State Open School/State Board of Education as per section 2.6 only

(a)

Details of Subjects passed for which transfer of credit is opted

¼d½ ukekadu la[;k ¼[k½ ijh{kk dk o"kZ

¼x½ Vhvkslh cksMZ dk dksM@

Enrolment No. (b) Year of Exam.

(c) Code of the TOC BoardWrite the code as per instructions mentioned at andsection 2.5 & 2.6

Appendix-J.

Ø- la-S.No.

fo"k;@Subjects(s),uvkbZvks,l dk fo"k; dksM

Subject Code of NIOS

izkIrkad@Marks Obtained

fl)kar@ iz;ksx@ dqy@Theory Practical Total

1.

2.

3.

4.

vkosnd dh ?kks"k.kk ¼lHkh vkosndksa }kjk Hkjk tk,xk½ / DECLARATION BY APPLICANT (TO BE FILLED BY ALL APPLICANT)

Bank Name : BankAddress :

I hereby declare that I have read and understood the conditions of eligibility and I fulfill the criteria for the course for which I seek admission. I have furnished all the

necessary documents and information correctly. I have filled this form in my own handwriting. I understand that my candidature is liable to be cancelled by NIOS in the

event of any information or document is to be found misleading or incorrect at any stage. I accept the rules as laid down in the Prospectus.

Date...............

Countersignature of Parent/Guardian Signature of Candidate

PermanentAddress

Bank details for Dr.Ambedkar National Scholarhsip (applicable for SC and ST only). For details please see section 4.11

________________________________________

eSa ?kks"k.kk djrk g¡w fd eSaus os lHkh

;ksX;rk 'krsZa i<+dj le> yh gSa ftl ikB~;Øe ds fy, eSa vkosnu dj jgk g¡wA eaSus lkjh t#jh lwpuk,a vkSj nLrkost lgh&lgh fn, gSaA eSaus [kqn vkosnu i= Hkjk gSA eSa tkurk gw¡ fd ;fn ;s

lwPkuk,¡ xyr ;k Hkzze esa Mkyus okyh gksrh gSa rks jk"Vªh; eqDr fo|ky;h f'k{kk laLFkku }kjk esjh mEehnokjh lekIr dh tk ldrh gSA eSa foojf.kdk esa fn, x, lHkh fu;eksa dk ikyu d:¡xkA

frfFk @

ekrk&firk@vfHkHkkod ds izfrgLrk{kj@ fo|kFkhZ ds gLrk{kj@

LFkkbZ irk@

_________________________________________________________________________________________________________________________________________________________

______________________________________________________________________________________

__________________________________________________________________________________ __________________________________________________________cSad dk uke@ cSad dk irk@

fiu @Pin

Lo&izek.ki= ¼mu lHkh ds }kjk gLrk{kj fd;k tk,xk tks fo|ky; NksM+us dk izek.ki= layXu ugha dj jgs gSa½SELF CERTIFICATE (to be filled by all those not enclosing School Leaving Certificate)

eS lR;kfir djrk g¡w fd eSa ek/;fed Lrj ds ikB~;Øe i<+us esa leFkZ gw¡Certified that I have studied enough to be able to pursue Secondary level course.

29. D;k vki Lo&izek.k i= ds vk/kkj ij ,uvkbZvks,l ds ekè;fed ikB~;Øe esa izos'k ysuk pkgrs gSa\ ;fn gk¡ rks Lo&izek.k i= ij gLrk{kjdjsaA@Whether you wish to get admission in Secondary Course of NIOS on the basis of Self Certificate. If yes, please sign the Self Certificate.

fo|kFkhZ ds gLrk{kj@Signature of the Candidate

leUo;d dk izek.k i=@Certificate From Coordinator

mijksDr rF;ksa dks ,uvkbZvks,l@lh-ch-,l-bZ-@lh-vkbZ-,l-lh-bZ-@lacaf/kr jkT; cksMZ@jkT; eqDr fo|ky; }kjk tkjh ewy vadlwph@izek.ki= ls lR;kfir dj fy;k x;k gSAAbove Statements have been verified with the original Marksheet/Certificate issued by NIOS/CBSE/CISCE/concerned State Board/SOS.

layXudksa dh tkaPk dhft,] lgh dk fu'kku ¼ ½ yxk,¡@3 CHECK THE ENCLOSURES, Please Tick ( )3

1.

OriginalAdmission Form

2.

Two photocopies ofAdmission Form alongwith enclosures

3.

Certificate of Date of Birth

4.

Certificate for SC/ST

5.

Transfer Certificate from the last school attended

6.

Proof of Residence

ewy izos'k&i=

izos'k i= dh nks izfr;k¡ nLrkostksa ds lkFk

tUe frfFk izek.ki=

vuqlwfpr tkfr@vuqlwfpr tutkfr izek.ki=

fiNys fo|ky; dk LFkkukarj.k izek.ki=

fuokl LFkku ds irs dk izek.k&i=

7.

Self Certificate regarding educational qualifications

8.

Photocopy of Marksheet of Class X Board Examination

9.

Certificate from the Employer for Ex-Servicemen

10.

Certificate from a Government Hospital for a handicapped person

11.

Original failure/compartment Marksheet of class X or XII for TOC

and

'kSf{kd ;ksX;rk lca/kh Lo&izek.ki=

nloha ijh{kk mÙkh.kZ djus dh vad rkfydk dh izfr

HkwriwoZ lSfudksa ds fy, fu;ksDrk ls izek.k i=

fodykax O;fDr ds fy, ljdkjh vLirky ls izek.k i=

Vh vks lh ds fy, d{kk nloha ;k ckjgoha cksMZ Qsy@dEikVZesaV dh ewy vad rkfydk vkSj

ysfeusV dh x;h vad rkfydk Lohdkj ugha dh tk;sxh

Laminated Marksheet is not acceptable

izekf.kr fd;k tkrk gS fd mi;qZDr layXudksa lfgr 'kqYd ds lkFk vkosnu i= lh/ks fo|kFkhZ ls izkIr gqvk gSA@It is certified that Application Form with fee is

received directly from the learner alongwith the above mentioned enclosures.

leUo;d ds eqgj lfgr gLrk{kjSignature with seal of Co-ordinator

Full Name ____________iwjk uke@

ikB~;Øe dk LrjCourse level

izR;sd fo"k; ds fy,ikB~;Øe 'kqYd

Course fee for each subjectVhvkslh dsfy, 'kqYd

Fee for TOCek/;fed Lrj

mPprj ek/;fed Lrj

250250

150180

'kqYd dk fooj.k @ FEE STRUCTURE

ikB~;ØeCourse

ek/;fed ikB~;Øe

mPprj ek/;fed ikB~;Øe

Secondary Course

Senior Secondary Course

(i)

(ii)

(i) For 5 subjects 1150 900 625

(ii) For an additional subject 180 180 180

For 5 subjects 1000 750 550For an additional subject 150 150 150

ikap fo"k;ksa ds fy,,d vfrfjDr fo"k; ds fy,

ikap fo"k;ksa ds fy,,d vfrfjDr fo"k; ds fy,

lkekU; oxZ NwV izkIr oxZGeneral Category ExemptedCategory

vuq tkfr@vuq tutkfr@HkwriwoZ lSfud@fodykaxSC/ST/Ex-Servicemen/Handicapped

iq#"k efgykMale Female