Navodaya Application Format
Navodaya Application Format
Navodaya Application Format
(To be filled in by the Parent/Guardian of the Candidate with the help of the
Headmaster/Headmistress of the School from where the candidate passed
Class V Examination)
Aadhar Number:
PHOTO
of student
2. Sex Male Female TG
3. (a) Category
Gen OBC SC ST
(b Caste :
4. Date of Birth
Date Month Year
5. Father’s Name :
6. Mother’s Name :
III IV V
(Separate certificate is to be obtained if the candidate had studied classes III, IV & V in
different schools)
CERTIFICATE
Certified that the information given above is true to the best of my knowledge
and belief. In case, any part of information furnished by me is found incorrect, the
admission of my child/ward may be cancelled. I am ready to produce the relevant
certificates issued by Competent Authorities as and when asked for.
Signature of PARENT/GUARDIAN
Name:
School Seal :
Desgn.:
Certified that the information given in pages 1 & 2 is found correct as per our
school records. It is also certified that Master/Kumari
was admitted in this School in Class on
(date) and passed Class on
(date).
Date:
UNDERTAKING BY THE PARENT/ GUARDIAN
Certified that the information given in the application form for admission into
Class VI in Jawahar Navodaya Vidyalaya,District: for the academic year
2021-22 for my ward is true to the best of my knowledge and belief. In case any part
of the information furnished by me is found incorrect, admission of my ward may be
cancelled at any time. I am ready to produce relevant certificates issued by the
competent authority to your office when asked in support of entries in my original
application
Signature of the
parent/Guardian
Address of parent/guardian:
Name
Street
Village
Mandal/Block
Pin Code:
Mobile No:
UNDERTAKING
Note: This is not applicable to SC/ST categories and all girl students and the parents
whose Income is below poverty line.
UNDERTAKING FOR MIGRATION
(TO BE FILLED BY PARENT IN PRESENCE OF PRINCIPAL, JNV)
I, Father/Mother/Guardian of Kumari/Master
of National Integration and as per the scheme at JNVs, 30% of the students of class IX
from one JNV have to migrate to another JNV from non-Hindi speaking area to Hindi
speaking area and vice-versa and I agree to abide by the rules of NVS in this regard.
Fullname:
Address:
Mobile No:
02. Father’sname :
03. Address :
05. Height _
06. Weight _
07. Abdomen _
08. Chest _
10 Ears _
11. Throat _
14. Skin _
15 Blood Group
16 Dental Hygiene
PHOTO OF THE
STUDENT _____________
CIVIL SURGEON
MEDICAL ANTECEDENTS
UNDERTAKING
1. Head Injuries
2. Puo- Intermittent
3. CHD- Congenital Heart Disease
4. AA – Acute appendicitis
5. Epliepsy – Convulsions (Injury, Fever)
6. Blood Disorders (Sickle cell Anemeia, Haemophillia)
7. Communicable Diseases (TB, Hepatitis A & B)
8. Skin Disease.
We further declare that our ward Master/Miss ____________ doesn’t have any previous
medical history which required/still requires prolonged or intermittent periods of medical
confinement either in a hospital/nursing home or in our house.
Certified that the information furnished above is true to the best of our knowledge. Any
wilful suppression or false information on the medical antecedents revealed later, would
make the admission of our ward invalid and liable for actions as deemed fit by the
Vidyalaya and Navodaya Vidyalaya Samiti.
DATE: NAME:
MOTHER’S SIGN:
NAME:
ADDRESS:
DISABILITY CERTIFICATE
If the candidate is selected under disabled quota he/she should bring the
certificate issued by the competent authority.
CATEGORY/COMMUNITY CERTIFICATE
(OBC/SC/ST)
Block:
District.
Office Seal:
Dated:
RESIDENCE CERTIFICATE
Village:
Town:
District:
State:
PinCode:
*The area of residence falls under the Rural /Urban area of the district
Certified that the information furnished by me is true and no fact has
been concealed.
Full name:
Address:
*Applicable for the students who seek admission through the studies in NIOS.
CERTIFICATE
(TO BE FILLED UP BY THE DISTRICT AUTHORITIES AND ISSUED UNDER THE SIGNATURE OF
TEHSILDAR TO THE PARENTS OF THE CHILD SELECTED FOR ADMISSION TO CLASS VI IN
JNVS THROUGH JNVST)
*The area where residence is located falls under (Rural/Urban) area of the
district .
Signature of Tehsildar
(With Seal)
*Applicable for the students who seek admission through the studies in NIOS.