ANNEXURE – I

Self ‐Declaration Format

I ________________, Father/Mother of Master/Miss

_________________________ age _____ years, resident of

_____________________________________________________________

___________________ (complete address), do hereby declare that the information

given in the admission form of the admission in Kendriya Vidyalaya,

and in the enclosed documents is true to the best of my knowledge and belief and

nothing has been concealed therein. I am well aware of the fact that if the information

given by me is proved false / not true at any point of time, admission has to be

deemed cancelled and will be liable to punishment as per guidelines of KVS and the

benefit accrued by me or my ward shall be summarily cancelled.

Date:-

Place:-

Signature of the Parent/Guardian

 CERTIFICATE FROM THE EMPLOYER
(Regarding Status of Employment & identification of Admission Category in KVS)
I Sri/Smt./Ms. _________________________________________ (Name of the Employer) ,
designation____________________________________ working in the office of
___________________________________________departmentof _____________________ , government of
___________________________ do hereby certify the following in respect of Sri/Smt./Ms.
__________________________________________ (Name of the Employee) whose son/daughter
____________________________________________ (Name of the Child) is seeking admission in Kendriya
Vidyalaya __________________________
01 Name of the Child for whom admission is sought (in Block Letters)

02 Class in which admission is sought

03 Full name of the employee (in Block Letters)

04 Designation of the employee

05 Employee Code / Employee Identity No.

06 Name of the office where the employee is presently posted

Status of Employment (Whether Permanent/ Regular/ Temporary/Contractual/

07
Part Time/ Adhoc/Daily Wage Basis/Casual -To be written clearly)
This office/organization is Central Government/Central Government
Autonomous body/PSU fully or partially financed by Govt. of India/State
08
Government/ Sate Government Autonomous Body/ PSU fully or partially
finance by the state govt. (To be written clearly)
Whether the employee is to be considered as an employee of Central
Government/Central Government Autonomous body/PSU fully or partially
09 financed by Govt. of India/State Government/ Sate Government Autonomous
Body/ PSU fully or partially finance by the state govt. (Any one of the above to
be written clearly)
Please write any one of the following which is applicable i.r.o. the child for
whom admission is sought
1. Children of transferable and non-transferable Central government
employees and children of ex- servicemen. This will also include
children of Foreign National officials, who come on deputation or
transfer to India on invitation by Govt. of India.
2. Children of transferable and non-transferable employees of
10 Autonomous Bodies / Public Sector Undertaking/Institute of Higher
Learning of the Government of India.
3. Children of transferable and non-transferable State Government
employees.
4. Children of transferable and non-transferable employees of
Autonomous Bodies/ Public Sector Undertakings/Institute of Higher
Learning of the State Governments.
5. Children from any other category
(i) Pay Level : _____________
(ii) Pay : ________
(iii) DA : _______________
11 Recent Pay/Salary of the Employee with proper Split up (iv) HRA : ___________________
(v) Any Other ______________
(vi) Any Other : ____________
(vii) Total :

12 Whether the employee is drawing the consolidated pay YES / NO

Place: _______________________
Date: ______________________
Signature of the Certifying Authority with Seal

Complete Address of the Office:

________________________
________________________
Telephone Number: _______________________
 KENDRIYA VIDYALAYA, NABARANGPUR

Documents required for ADMISSION 2020-21 ( If applicable )

 Certificate of proof of age in the form of a birth certificate issued by the
competent authority.
 For grandchildren of Hon’ble Member of Parliament and PSU employees
a proof of relationship of either of the child’s parents with the Hon’ble
Member of Parliament or PSU employees would be needed.
 For grandchildren of KVS employee a proof of relationship would be
required.
 A certificate that the child belongs to the Scheduled Caste/Scheduled
Tribe/EWS/OBC(Non-Creamy Layer)/BPL/Disabled, wherever
applicable, issued by the competent authority in concerned State
Government/Union Government.
 A certificate from competent authority certifying the child to
be handicapped, wherever applicable.
 A service certificate ( by regular govt. employees) showing the number
of transfers during the preceding 7 years duly signed and stamped by the
head of office bearing the name, designation and other relevant particulars
in block letters.
 A certificate of retirement for uniformed Defence employees.
 Proof of Residence.
 Copy of online registration form.
 Original blood group certificate.
 Copy of Aadhar card of Candidate.
 Two coloured passpost size photograph of the candidate.
 Identity proof of Parents.
 Affidavit of Single girl child, wherever applicable.
 Declaration of Residence distance.
 Declaration of self arrangement of transportation to and fro the school.
 Document relevant to RTE.
 Any other, wherever applicable.

NOTE:
(I) Mere registration will not confer a right to admission.
(II) Incomplete application forms shall normally be rejected.
(III) Admission secured on the basis of any wrong certificate shall be
cancelled by the Principal forthwith and no appeal against such action of
the Principal shall be entertained.
 सेवा प्रमाण पत्र / SERVICE CERTIFICATE
( Central Govt. / केन्द्रीयसरकार )
प्रमाणित णिया जाता है िी श्री / श्रीमती ..................................................................................................,
......................................................................... िायाालय/ मंत्रालयमें णियणमत िमाचारी िे रूप में
िायारत हैं ।वे रक्षा सेवा / िेन्द्रीय ररज़वा पुणलस बल / सीमा सुरक्षा बल / एि. एस. जी./ एस. पी. जी./ सी.
आई. एस. एफ./ िेन्द्रीय सरिार /स्वायत्त संस्था अथवा / सावाजणिि क्षेत्र िे उपक्रम जो पूिा या आं णिि रूप
में िेंद्र सरिार से णवत्त पोणित हैं िे णियणमत िमाचारी हैं तथा उििी सेवा अस्थािां तरिीय/पूिा भारत में िहीं
भीस्थािांतरिीय।

Certified that Shri/Smt. ……………………………….....………………........................... is

working as regular employee in the Office / Ministry of …………………………………………….……………….. .
He/She is aregular employee of Defence Service / CRPF / BSF / NSG / SPG / CISF / Central Govt. /
Autonomous Body / Public Sector Undertaking fully financed / partially finance by the Central Govt. and
his / her services are non-transferable / transferable anywhere in India.

स्थाि/Place………………………………….. िायाा लय अध्यक्ष िे हस्ताक्षर

णििां ि/Date………………………………….. ( िाम पि और िायाा लय िी मोहर सणहत )
Signature of head of the Office
( With Name, Designation and Office Stamp)

िायाा लय िा पूिा पता एवं िू रभाि संख्या

:............................................................................
Complete address and Telephone No. of office

सेवा प्रमाण पत्र / SERVICE CERTIFICATE

( StateGovt. / राज्यसरकार )
प्रमाणित णिया जाता है िी श्री / श्रीमती
.............................................................................................,………………………………………………………………………………िायाा
लय/ मंत्रालयमें णियणमत िमाचारी िे रूप में िायारत हैं ।तथा उििी सेवा अस्थािांतरिीय है/पूिाराज्य में िहीं
भीस्थािांतरिीय।

Certified that Shri/Smt. ……………………………………………………………………. is working as regular employee in

the Office / Ministry of…………………………………………………….. and his / her services are non-transferable /
transferable anywhere in State.

स्थाि/Place………………………………….. िायाा लय अध्यक्ष िे हस्ताक्षर

णििां ि/Date………………………………….. ( िाम पि और िायाा लय िी मोहर सणहत )
Signature of head of the Office
( With Name, Designation and Office Stamp)

िायाा लय िा पूिा पता एवं िू रभाि संख्या

:............................................................................
Complete address and Telephone No. of office
 स्थानाांतरण सां ख्या प्रमाण पत्र / CERTIFICATE OF NUMBER OF TRANSFERS

मैं............................................................................
..........(िाम)................................................
.................................................. ( रैं ि/पििाम)
........................................................................
( िायाा लय) एति द्वारा प्रमाणित िरता / िरती हूँ णपछले सात साल ( 31.03.2019) मैं एि स्थाि से
िु सरे स्थाि पर मेरे .......................................................... (
अंिो व िब्ों में ) स्थािां तरि हुए णजििा णववरि णिचे णिया गया है

I,
......................................................................................
.(Name)................................................. (rank/designation)
of...................................................... (office), do hereby certify that during
the past 7 years (up to 31.03.2019) I have been
transferred.......................................times(in figures & in words) from one station
to another,the details of which are given as under:-
क्रम सं िायाा लय स्थाि रैं ि/पििाम णििां ि ठहरिे िी आिे िसंख्या
S.No. Office Place Rank/ Date अवणि Order No.
Designation से ति Period of
From To stay

मैंजािता/जािती हूँ णि यिी उपरोक्त तथ्य गलत पाए गए तो मेरा बच्चा िेन्द्रीय णवद्यालय में प्रवेि िे
णलए अयोग्य हो जायेगा l
I know that if the above mentioned facts are found incorrect, my child will be disqualified for admission
in KendriyaVidyalaya.

माता/ णपता िे हस्ताक्षर

Signature of Parent

Note : Minimum period of posting/stay at a place should be minimum six months.

 Self-declaration for distance between school and residence

I……………………………………………….father/mother of………………………………………………….
bearing application submission code…………………………………………………………..declare
that the radial distance between school and our residence is
…………………..kilometres (kms).

Date:…………………......... Signature of parent:…………………………………………

Undertaking

I………………………………………………father/ mother of………………………………………………….

hereby undertake that I will arrange the transportation of my son/daughter to
and fro Kendriya Vidyalaya, Nabarangpur.

Date:…………………………… Signature of parent:…………………………………………

30.03.2021
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Designation

Designation
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