Appendix11
- 1. GOVERNMENT OF KERALA DIRECTORATE OF HIGHER SECONDARY EDUCATION APPLICATION FOR ADMISSION TO THE HIGHER SECONDARY COURSE (2016-2017) Note:- Applicants are requested to read the prospectus and instructions carefully before filling up the application form. Furnishing false information, if any, will be a disqualification for admission. 1. Code & Name of Qualifying Examination : 2. Register Number : 3. Month and Year of Passing : 4. a) Code and Name of School in which the applicant studied for SSLC or equivalent examination : …………………………………………….. b) Whether passed in Board Examination : (Tick the relevant column) 5. . a) Name of Applicant (in Block Letters. Initials after the name ) : ……………….……………………………………………………… b) Aadhaar Number : 6. Gender (Tick the relevant column) 7. Category Name & Code : 8. Caste and Religion : 9. Date of Birth : 10 a). Name of Mother : ………………………………………………………………………. b) Name of Father : …….……………………………………………………………….. c) Name of Guardian : …….……………………………………………………………….. ACKNOWLEDGEMENT District : Received the application from . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .with Application No . . . . . . . . . ………………... Place: Date: (SCHOOL SEAL) Name and Signature of the Principal Yes No Day Month Year Application No. Female Male Application No. DvgyÍb 11
- 2. 2 11. Whether the applicant belongs to OEC : (Tick the relevant column) 12. Whether the applicant belongs to Linguistic Minority: If ‘Yes’ specify the (Tick the relevant column) language: . . . . . . . . . . . . . . . . 13. a) Whether the applicant is Differently Abled (Tick the relevant column) : b) Write the Reference Number in the Box (See instructions for item No. 13) : 14. Place of Residence (Code & Name of Place): ……………………… ……………………… ……………………… ……………………… 15. Permanent Address : ………………………………………………..………………….. ………………………………………..………………………….. ………………………………….. PIN :………………………….. 16. Address to which communications are to : …….…………………………………………………………….. be sent ………………………………………………………………….. ………………………………… PIN :……………………….. Phone Number (with STD Code): …………………………………… E-Mail Address (if any):. …………………………………………….. 17. Whether the applicant is eligible for bonus points under the following category(Attach copies of supporting documents) 18. Participation in Sports (Attach copies of certificates) State Level Participation (Write the number of items participated) District Level (Write the number of grades won in the relevant boxes) 19. Participation in Kerala School Kalotsavam (Attach copies of certificates) State Level Participation (Write the number of items participated) District Level (Write the number of grades won in the relevant boxes) 20. Whether qualified in the National/State Level Test for the National Talent Search Examination (Attach copies of certificates) Yes No Orthopaedically Challeged Blind Deaf Mental/Brain Diseases State District Taluk Grama Panchayat/ Municipality/ Corporation NCC/ Scouts & Guides/Swimming /Student Police Cadet as detailed in Para11 Dependent of Jawan killed in action Dependent of Jawan in Service or Ex-Service 1 st Place (but not participated in state level) 2 nd Place 3 rd Place Participation A (but not participated in state level) B C Participation Yes No Yes No
- 3. 3 21. (a) Details of participation in co-curricular activities (Attach copies of certificates). Write the number of grades won in the relevant boxes. A Grade B Grade C Grade D Grade E Grade (b) (Tick the relevant boxes) 22. (a) No. of chances taken for passing the SSLC or equivalent examination : Reg. No. Month Year (b) If more than one chance, state the Reg.No, Month & Year of previous three appearances preceding the latest : 23. (a) Grades obtained for Qualifying Examination (SSLC March 2016) (Self attested Photostat copies of the SSLC to be enclosed) Subjects Lang I Lang II Eng Hin SS Phy Che Bio Maths IT Grades (b) Grades obtained for Qualifying Examination SSLC March 2007 to March 2015 (Self attested Photostat copies of the SSLC to be enclosed) Subjects Lang I Lang II Eng Hin SS Phy Che Bio Maths IT Grades (c) SSLC 2005, 2006 (Grading), SSLC(Old Schemes), CBSE, ICSE and other streams(Self attested Photostat copies of certificates to be enclosed) State Science Fair State Social Science Fair State Maths Fair State IT Fest State Work Experience Fair Red Cross Social Science Club Science Club Nature Club Forestry Club Maths Club Health Club Philately Club Debating Club Oratory Club IT Club Literary Contribution (Periodicals) Literary Contribution (School Magazine) Participation in Scouts & Guides (but not awarded Rashtrapathi Puraskar or Rajya Puraskar) 1. 2. 3. Sl. No. Subjects Awarded Grades / Marks Max. Marks 1 2 3 4 5 6 Sl. No. Subjects Awarded Grades / Marks Max. Marks 7 8 9 10 11 12
- 4. 4 24. Schools and Subject combinations in the order of preference(to be filled after reading para 18 of the Prospectus, Appendice 3,4 and 9) DECLARATION I do state that all the information furnished above is true. I know that any false information in the application form will result in the cancellation of my candidature. Name and Signature of Parent/Guardian Signature of applicant Place : Date : FOR OFFICE USE ONLY Entered by ……………………………………. Verified by …………………………………….. Pref. No School Code Combination Code 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 Pref. No School Code Combination Code 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50