Dooars International Public School
Sonari-Kakribari, PO: Kharija-Kakribari, Gopalpur, Coochbehar - 736 179, WB
Ph: +91 3582 240 062, e-mail: contact@dipscoochbehar.com, Website: www.dipscoochbehar.com
Form No
Paste
Application for admission to recent
coloured
Class: passport size
photograph
Academic Session here
Personal details of the applicant
Name of the applicant: ___________________________________________________________________
(Surname) (Middle name) (First Name)
Date of birth: ____________________________ Sex: Male / Female Nationality: _________________
Religion: ______________________ Category: Gen / SC / ST / OBC Blood Group: _______________
Mother tongue: ___________________________ Languages known: _____________________________
Does the child have any medical or psychological condition? Yes / No (If ‘yes’, please provide
details/Relevant documentation.) __________________________________________________________
Educational details of the applicant
Name of the present school: ______________________________________________________________
Address: _________________________________________________________________________________
Class last attended: ___________________________________________________ (Marksheet enclosed)
Reason for leaving the present school: _____________________________________________________
Admission related details
Admission seeking to class: ______________________________________________________________
Would you like to avail the transport facility for the child? Yes / No (If ‘yes’, please fill the form for
availing the transport facility.)
Would you like to avail the Boarding facility for the child? Yes / No (If ‘yes’, please fill the
‘Boarding’ form.)
Details of the Parents / Guardian
Father’s Name: ___________________________________________________________________________
Age: _______________________ Nationality: _________________ Occupation: ___________________
Educational Qualification: ______________________ Contact No: _____________________________
Mother’s Name: __________________________________________________________________________
Age: _______________________ Nationality: _________________ Occupation: ___________________
Educational Qualification: ______________________ Contact No: _____________________________
Address: _________________________________________________________________________________
_________________________________________________________________________________________
Local Guardian’s Name: __________________________________________________________________
Age: _______________________ Nationality: _________________ Occupation: ___________________
Educational Qualification: ______________________ Contact No: _____________________________
Address: _________________________________________________________________________________
_________________________________________________________________________________________
Information of the Sibling/s
Name: _____________________________ __________________________ _________________________
Age: _____________________________ __________________________ _________________________
Gender:____________________________ __________________________ _________________________
School: ____________________________ __________________________ _________________________
Grade: _____________________________ __________________________ _________________________
Declaration
I/we, hereby, declare that the information stated in the application form are complete and true to the best of my/our
knowledge and belief. I/we understand and agree that any misrepresentation or major omission of facts will justify the denial
of admission, the cancellation of admission, expulsion. I/we further pledge to abide by the rules and regulations of the school
already enforced or to be enforced from time to time.
If, in spite of normal precaution and necessary measures taken by the school authority any mishap, accident or injury occurs
during the period of my ward/s stay in the school or during educational tours, excursions or camps as and when arranged by
the school. I/we will not hold the institution or any other members of the staff wholly and partly responsible for that.
Date:
Signature of the parents/guardian
For office use only
Date of issue: Date of admission:
Registration No.:
_____________________________ ___________________________
Signature of the Office Asst. Signature of the Principal
