Affix self attested recent passport size

Photograph

GOVERNMENT OF WEST BENGAL DIRECTORATE OF SCHOOL EDUCATION

BIKASH BHAWAN (7TH FLOOR), SALT LAKE KOLKATA - 700091 To

Headmaster / Headmistress

 (Name of the School)

 

Application for admission to class — XI in West Bengal Government Schools for the session —2019 -2020.

1. Name of the Candidate (in Block Letters)

2. Date of Birth

3. Category (Gen / SC / ST / OBC-A / OBC-B / PH) 

4. Nationality

5. Address with PIN for communication (in Block Letters) :

6. Telephone No. i) Land Line :

ii) Mobile :

7. Father's Name & Occupation

8. Mother's Name & Occupation

9. Guardian's Name

10. Relationship with candidate

11. Guardian's address with PIN & Ph. No.

12. Name & Address of the School last attended

13. a) Name of the Examination passed

b) Name of the Board

c) Year of Passing No. 

14. Marks obtained in the Board Examination :

Subjects Bengali English Total

(Language Group) Math Phy.Sc. Life.Sc. Total. Sc.Gr. History Geography Total

Humani

-ties Gr. Additional Total

(Excluding

Additional

Full

Marks 100 100 200 100 100 100 300 100 100 200 100 700

Marks

Obtaine d

Percentage of Marks 

15. Subject preferred within the SET mentioned in notification :

1 2 

3 4

 

N.B. 1. Application Form not duly filled up would be rejected.

2. Application Form must be accompanied by Character Certificate from the Head of the Institution last attended and self attested copy of Admit Card, Mark Sheet of the Madhyamik or equivalent Examination and Reservation Certificate issued by the Competent Authority.

 

Signature of the Guardian with Date Signature of the Candidate with Date

 

Counterfoil of Application Form

No 

Received an Application Form duly filled up from........................................................................... (Name of the Candidate) for seeking admission to class XI for the session 2019 -2020.

SET -1 / SET -11 / SET- 111

Receiving Officer

School Authority with Official Seal

Vote :lfthe candidate is selected for admission, original Admit Card and Mark Sheet of last Examination passed are to be produced with the counterfoil of Application Form. Claim for admission may be rejected if the selected candidate fails to produce the necessary documents and report the School Authority for admission on due dates.