SS OMANOT FCT FEMA PETA ASL oro one Grameen Mukt Vidhyalayi Shiksha Sansthan waa ae aha ont ioe orang a 2 et Facey far wena ¥ Get—1, 2, 3. White in Hind! or English (CAPITAL). Use only Blue/Black Ball Paint Pen, Wrte one letter in one Bax: Do not write outside the Boxes, Bo not use Photocopy of this form. Use Numericais oniy ae eS ay oA Gas Soy AR) das A a are dia ange Or wr Owed wR] gw a A ew Sia oo ema Tact ad Ravel oe wa A ae oy) Ger ser ae A wees OA wD A ae eR RE AY SAO eS ATI aN Sew A Sey we | Eon a oT Oe eT ST fin for wa ee me en oye en sew ae cheray ore | Important: To be ils by the candidate n DUPLICATE. Compl ‘Should bo doposted wis Aceodtes nate on or olor the lst dato. Inomplet admission forms wil bo summary Tojectod and foo forfetod wahout ary snbmation othe cand 1 forms wit attosted photo copies of carfcata and feos DONOTATTEST carne arg slap siftard /Aadhar Card Number Mandatory Re {LT A /Name of Candidate in fullin CAPITAL Letters 2. Rar ar afte 7 Gel AIH/ Father's oF Guardian's Name In CAPITAL Letters 3. ren a {Bete AT ye API/ Mother's or Mentor Mother's Name in CAPITAL Letters 4a. ca-armere # farg er /Postal Address in CAPITAL Lottors var / Address ‘aT /Dietrct waysae (TTT TPT? TT TTT) as 4b. earth a /Permanent Address Pin Code wer/addess (TT TT TTT TTT??? Eroq fora / District 04 / State ‘1 ws /Pin Code 5 AI Date of Binh Gla). GeV Male Lo] «renin /oisanity ob). R=/Female 7, Arh / Category ln 7daio a Mont at = /Disadvantaged Group ida Bia agaae Sy ates end on a A RS [|b ‘Whi Course Applied for please put the Mark <~ % = TH / Name ofthe Course [| [utara ate wear Subject Code No stoner tan) Sessa fs | (C00 C00 COO Co Oo Co oo 1. stare a art / Medium of Study 12. ase / Nationality 13. 4/Religion fe ama Gamat whens wt baat hae tata ae ae Your Previous Qualicaton Puck inside the AppropateBox|| Year of Passing X and xilClass Examination x xi v w w E] ww (Bieaso enclose the ralevent papers! Certificates posiively as necessary) “FS m1 7 /Name fo Bord x Fa xiver set |] ean se Se havea sure 816,iftard fa / Compulsory Subjects ~ ats / Code 17.tcofera fora / Optional Subjects - ais / Code ‘Uden ETT FWOT / Declaration by the Student " 78 AA wae eH Ae Ho FRA aT eT ) 16 tH 8 ee A ape tg ser Mer e/a ELAR we Re antes HE A eee ee uae id or Ha eb ee Tg MTA Aw BA e/a oh a a/R hereby declare tht Ihave read and uertad the Prospectus of Grameen Mukt Vidhyalayt Shiksha Santhan snd fer being fly sted with be esopniton satus, ave applied orexamination [have the minim gsifctionpresribod forthe xaminasion andthe norman given nthe appt ome cowzectAtany stage, on ing te dss incorect Boas ghto canes te examination ot dba fom appearing inte examination, rons to flow theules andreplations ofthe Bos seer ae Foret fn eens A be A ate oA Ag onde et PET Sher ar tert “The flowing decoration mus be fornia by each stent appearing inthe ex seen MuktVidylay Shiksha Sant aor pe Rear ere Barer / Pe Pee met a 8 ge oe Ae E/E eh Re AE eS Rete AA T/T A Rae pera hd # gear ge 8 8 AS Poa a sg e/a ae Yee EO wT /EM "have eadabou Revogutow Rules and Regulations aespestof the programmes conducted by Grameen Mat Vidhyalayi Shiksh nally ‘atalyng mse his applieaion in submited I ature under no czcunstanee I hll go agains! the rls and egulaons ofthe Board Ia the even of any spate sagrestoabideby he devsion ofthe Board Chairman ors Commitee of Governing Body consttued by andi cision shall bebindngonallconcerned. Dispute/Legal Jurisdiction: All disputes willbesbjettoDethi Justin ony. wt Rare Ret maa & st BH fer Rar aioe & aerare (RR Be) Fendt & weer CCountersgnatures of PareriGuardian Date Signature of Candida ate ieoat at or adh ara ot (icf Tl} CHECKLIST OF ENCLOSURES Pete tok 13a EE A Dupe copy of he aisin fom C=] ea wet) FAT A Corian! Educational qalifeaton sah ee ' Paved nf ste) Pholooraph dy pasted [aa vara (eR aH, 8) Experience Crit, appiabieL—] wrHR EHH Corifcate of Date of ith 2 fa Date: Full Signature with seal of DD Full Signature with seal of AD aid ih tem got wits wee Pl ete ae eearate emt (areow xra & are /Enrolment Number (tobe given by Offcs) DDIAD Coc... PAINE Date of Binh nei ear fa GSE / Date oF Bie ‘tb. soure ard sia offer / Aadhar Card Numbor Mandatory oP eee R/O we /Mortn Ww /Yoar ‘We PHOTO OF STUDENT DONOTATTEST 06H I AIS / Name of the Course [a. Fase wis wei / Subject Code No. OOODOODODOODOCOODoO Sr es a 4, fRemeif wr YET ATH /Name of Candidate in fll in CAPITAL Letters 5, Ret ay sifturaar wr ygI ATH / Father's of Guardian's Name in CAPITAL Letters 6, sre a (Bae) Ta ¥gI-API/Mother's or Mentor Mother's Name in CAPITAL Letters 7. wa-arrnere # fare st /Postal Address in CAPITAL Letters vai / Address fra / District ou / State fa ahs /Pin Code 38 /E-mail eet BS/ STD Code eis ag /Telephoneltobile IM / MIG / Telephone/Mobile a b. Fee Details:- The Students are permitted to pay the annual fees in one installments in advance, Demand draft should be payable at Delhi only. Demand drafts payable outside Delhi will not be accepted. Demand Draft forthe prescribed fees is to be drawn in favour of "GRAMEEN MUKT VIDHYALAYI SHIKSHA SANSTHAN" payable at Delhi. Cheque, Postal Orders and Money Orders willnot be accepled under any citcumstances. Fees once paid shal neither be refunded nor adjusted towards any other payment, Detail of Full Fee Paid Rs.. Dated. Bank Draft No. Drawnon fa Dates Full Signature with seal of DD Full Signature with seal ofAD “Soo ph een gee ate yea phen ge eeList of Subject Code & Exam Pattern 10th (Secondary) 12th (Sr. Secondary) code | subject Raper in| wm ode | subject paper in| an 201 [Hindi 1 [100 301 [Hindi 1 [100 202 | English 1 | 100 302 | English 1 [100 203 [Sanskrit 1 [100 303 [Sanskrit 1 __[100 204 [Urda T__ [100 304 [Urdu 1__[100 205 [Asami 1__|i00 305 [Asami 1 [100 206 [Bengal T__ [100 306 [Bengali 1__ [100 207 | Gujarati 1__| 100 307 | Gujarati 1 [100 208 [Kannada 1 [100 308 [Kannada 1 [00 208 | Kashmir 1__| 00 308 | Kashmir 1 [100 210 [Malayalam 1 [100 310 [Malayalam 1 [100 21 [Manipur 1 __| 00 31_ [Manipur 1 [100 22 [Marathi 1 __| 100 312 [Marathi 1_[100 213 [Mize 1 __|a00 313 [Mize 1 [100 214 [Oriya a |a00 314 [Oriya 1_ [100 215 [Pali 1 __|a00 315 [Pali 1 [100 216 [Punjabi a__| 100 316 [Punjabi i _|i00 217 [Tamil 1__| 200 317 [Tamil 1_ [100 218 [Telugu a__| 100 318 [Telugu a_[100 219 | Kokborok a [100 319 | Kokborok 1 [100 221_ [Mathematics 1 __| 100 321_[Paysics 1_[70+30 223 [Science 1__| 80x20 322. [Chemistry 1 _[70+30 224 [Social Studies 1 [200 323 [Mathematics 1 [100 225 [Home Science 1 | 80+20 324 [Biology i _[70+30 226 [Business Administration | 1 | 100, 325 [Accountancy 1 [100 227 [Computer Science & [1 | 80+20 326 [Statistics 1 _[70+30 228 [Draw & Paint 1__|a0r20 327 [Business Mathematics | 1 | 100 328 [Entrepreneurship 1_[70+30 329 [Business Organization | 1 | 100 330 [Sociology i__[i00 331 [Economics 1 [100 332 [History i_[i00 333 | Geography 1_[70+30 334 [Political Science 1_ [100 335. [Home Science 1_[70+30 336 [Computer Science 1 _[70+30 337 [Information Technology| 1 | 70+30Format of Affidavit for issue of Candidate is alive/not in prison/personally present for admission/Exam to be executed on a non-judicial stamp paper of Rs. 10/- and attested by Notary Public/Oath Commissioner. DAVIT Slo [Dio / Wio Resident of aged about -having professional address at.. “do hereby solemnly affirm and declare as under:- 1. ‘That I wish to take admission/Exam of Secondary (10thy/Sr. Secondary (12th) at the Centre with the RC/AC Code... ..from The Grameen Mukt Vidhyalayi Shiksha Sansthan (GMVSS). ‘That, at the time of Admission/Exam, I am Alive and personally present for the same at above said Centre. 3. That, at the time of Admission/Exam, I am not in prison and have no criminal record and personally present for the same ataabove said Centre. 4, That in case, the above said information found lie down, then my admission/exam will be cancelled automatically and Grameen Mukt Vidhyalayi Shiksha Sansthan can take judiciary action against my candidature and will not declare the result/issue any Marksheet/Migration/Certificate for the same. DEPONENT VERIFICATION Verified that the contents of the above affidavit are true and correct to the best of my knowledge and belief and nothing has been concealed there from Verified at onthis day of. DEPONENT