APPENDIX FORM SELF DECLARATION CUM APPLICATION FOR GRANT OF RECOGNITION OF SCHOOL (See sub-rule (1) of rule 11) The District Educational Officer (Name of District & State) Sir, | forward herewith with a self declaration regarding compliance with the norms and standards prescribed in the Schedule of the Right of Children to Free and Compulsory Education Act, 2009 and an application in the prescribed proforma for the grant of recognition to. .(Name of the School) with effect from the commencement of the School year 20. Yours faithfully, Enclosure: Place: Date: Chairman of Managing Committee/ManagerA.School Details Name of School Academic Session District Postal Address Village/Cit Tashil Pincode: Phone No with STD Code Fax No. E-mail address if any =)=]e]e]SJolalayon[= 0 1 Nearest Police Station B.General Information 41 Year of Foundation 2_| Date of First Opening of School 3_[Name of Trust/Society/Managing Committee 4__| Whether Trust/Society/Managing Committee is registered 5__| Period upto which Registration of Trust/Society/Managing Committee is valid 6 | Whether there is a proof of non-proprietary character of the Trust/Society/Managing Committee supported by the list of members with their address on an affidavit in cop) 7 [Name official address of the Manager/President/Chairman of the school Name Designation Address Phone 0) (R) 8 | Total Income & Expenditure during last 3 years surplus/deficit Year Income: Expenditure ]| Surplus/deficit | C.Nature and area of school 1 Medium of Instruction 2 Type of School (Specify entry & exit classes) 3 Ifaided, the name of agency and percentage ofaid 4 | If School Recognised a Ifo, by which authority *Recognition number 6 | Does the school has its own building or is it Tunning in a rented building 7 | Whether the school buildings or other structures or the grounds are used only for the purpose of education and skill development? 8 _| Total area of the School 9 _| Built in area of the school D.Enrollment Status Class No. of Section No. of Students Boys Girls Total Pre-Primary V Vv Vi Vil co] | Sofa] a oo]o]] Vill E.Infrastructure Details & Sanitary Conditions Room Numbers Average Size 1_| Classroom Office room-cum-store room-cum-Headmaster Room 3__| Kitchen - Cum - Store Other Facilities Whether all facilities have barrier free access Teaching Learning Material (attach list) Sports & Play equipments (attach list) S)eNf=|n Facility books in Library © Books ( No. of books) + _Periodical/Newspapers Type and number of drinking water facility olor Sanitary Conditions 23(Type of W.C & Urinals (iNumber of Urinals/Lavato Boys ries Separately for for Girls (ii) Number of Urinals/Lavatories Separately G Particulars of Teaching Staff 1. Teaching in Primary/Upper separately) Primary exclusively ( details of each teacher Teacher Name Father/Spouse Name __] Date of Birth (1) (2) (3) Academic Qualification | Professional Date of Appointment Qualification (6) (5) Class Assigned Teaching experience _ | Trained or Unmarried (9) Scale of pay Gross Salary per (10) month (11) separately) 2. Teaching in Both Elementary and Secondary (details of each teacher Teacher Name F. (1) ather/Spouse Name Date of Birth (3) Academic Qualification | Professional Date of Appointment (4) Qualification (6) (5) Class Assigned Teaching experience __| Trained or Unmarried (7) (8) (9) ‘Scale of Pay Gross salary per month (10) (11)3. Teachers in High School Teacher Name Father/Spouse Name _| Date of Birth (1) (3) ‘Academic Qualification | Professional Date of Appointment (4) Qualification (6) (5) Class Assigned Teaching Experience Trained or Untrained (7) (8) (9) Scale of pay Gross Salary per month (10) (11) 4. Headmaster / Principal Teacher Name Father/Spouse Name Date of Birth (4) (2) (3) Academic Qualification | Professional Date of Appointment (4) Qualification (6) (5) Class Assigned Teaching Experience Trained or Untrained (7) (8) (9) Scale of pay Gross Salary per month (10) (11) H. Curriculum and Syllabus 1 | Details of curriculum & syllabus followed in each class(Upto VII) 2_| System of Pupil Assessment 3 | Whether pupils of the school are required to take any Board exam upto class VIII?\.School fee SI.No. Class Fee 1 Pre-primary Class-I Class-II Class-lil Class-V_ Class-V1 Class-VII 2 3 4 5 Class-IV 6 7 8 9 Class-Vill J. Neibhourhood area for purpose of section 12 (C) K. Certified that the school complies with the Fire Safety Rules, Municipal by laws and traffic regulations. L. Certified that the school has also submitted information in this data capture format of District Information System of Education with this application M. Certified that the school is open to inspection by any officer authorized by the appropriate authority N. Certified that the school undertakes to furnish such reports and information it may be required by the District Educational Officer from time to time and complies with such instructions of the appropriate authority or the District Education Officer as may be issued to secure the continued fulfilment of the condition of recognition or the removal of deficiencies in working of the school. ©. Certified that records of the school pertinent to the implementation of this Act shall be open to inspection by any Officer authorized by the District Education Officer or appropriate authority at any time, and the school shall furnish all such information as may be necessary to enable the Central and / Or State Government/Local Body or the Administration to discharge its or his obligations to Parliament / Legislative Assembly of the State/ Panchayat/Municiapal Corporation as the case may be. Sdi- Chairman/Manager Managing C Committee fesse .. School