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APPLICATION FORM
NATIONAL MEANS-CUM-MERIT SCHOLARSHIP EXAMINATION, NOVEMBER
 – 
2011
State Level 12 digit Roll Number (to be filled by the DEO Office) .Class State Code Year Dist Code Centre Code Sl. No3 4 0 1 1
1.
 
Name of the candidate (Do not write Miss/Master)
2. Father’s Name (Do not write Mr./Dr./Prof.)
 3. Date of birth (as per school records) 4.Sex 5. Area of Candidate residesDate Month YearMale Female Rural Urban6. Community (Code) 7. Disability Status of the Candidate (Code)8. Postal address for correspondence (Do n
ot write father’s or 
your name)9. Name and address of the institution in which studying at Class VIII level10. Name and address of the institution in which studied at Class VII level11. Type of the institution in which studying at Class VIII level (see definition overleaf*) 12.Area of school LocatedGovt ZPHS Municipal Private Aided Rural Urban13. Medium of Examination (Code)
14.Father’s
Education
15. Mother’s
Education19. Telephone /MobileOf Candidate20.VII ClassNumber of SubjectsTotal MarksPercentage of Marks
To be filled in by the Head of the Institution
Certified that:(1) Master / Miss.............................................is a regular student of this School/In
stitution. He/She has secured……. Marks out of 
600. The percentageof marks in
the class VII is……….
 (2) The parental Income (income of both the parents) is less than Rs.1,50,000/- p.a. as per the certificate issued by the Mandal Revenue Officer/ anyauthority authorized by the Government by G.O. to issue Income certificate and produced by the candidate.(3) The applicant belongs to Scheduled Caste/Scheduled Tribe/ Backward Caste-A/B/C/D as per caste certificates issued by Mandal Revenue Officer/ any authority authorized by the Government by G.O. to issue Caste certificate and produced by the candidate.(strike off which are not relevant)Signature of the Headmaster/Headmistress With SealPinCodePinCodePinCode16. Father
’s O
ccupation
17. Mother’s
Occupation 18.Parental Annual Income21. Place: 22. Signature of the Candidate:DateRead the instructions carefully given on the next page before filling the application form. You may take thehelp from your teacher/parent for filling up application form.
Date of Examination : 20-11-2011 (10.00am to 01.00 pm
)Examination fee in the form of DD in favour of the
DIRECTOR OF GOVT. EXAMS., AP HYDAmount DD Number Date of DD Name of Bank
Rs.
SBI/SBH
 
Space for thePhotograph(Passport size andBlack and white)The Photograph shouldbe attested by theby the Head of theInstitution
 
 
Coding Plan
Read Instructions carefully before filling up the Application Form
1. Use only Blue or Black Ball Point Pen. WRITE IN CAPITAL LETTERS. Do not mark or write outside theboxes.2. Leave one box blank between two words.
Limit your name and / or address within the space provided forit.
Please see example as given below.3. Tick (
 
) only one of the appropriate boxes in item nos.4, 5, 11 and 12.4. Please write code number in item nos. 6, 7, 13, 14, 15, 16, 17&18 as given below.5. It is the responsibility of the candidate and the principal of the school to submit the filled in Application to theconcerned District Educational officer before the last date. No request for condoning delay in submission willbe entertained whether it is due to the fault of the candidate or the Headmaster / Principal of his/ herinstitution.6. Incomplete or defective applications are liable for rejection.7. Candidate area means the area to which the candidate resides..
Example for writing Name and Address
Father’s Name
: B V S S R A OPostal Address: Do not try to write complete address in one line. Break it appropriately as shown below.1 / 4 0 2 K A L Y A N IL B N A G A R PIN 5 0 0 0 6 8
Community Code Disability Status Code Parental Annual Income Code Medium Code
GENERAL 1 Orthopaedic 1 upto Rs.50000/- 1 TELUGU TSC 2 Hearing Impaired 2 Rs.50001/- to Rs100000/- 2 ENGLISH EST 3 Visually Impaired 3 Rs100001/- to Rs150000/- 3 HINDI HBC-A 4 None 4 (refer to item No.18) URDU UBC-B 5 (Refer to item No.13)BC-C 6BC-D 7
Education of Father or Mother
(Refer to itemNos.14 & 15)
Father’s / Mother’s Occupation
 
(Refer to item Nos. 16 & 17)
Education Code Occupation Code
upto Primary 1 Professional, Technical and Related Worker 1Upper Primary2Administrative, Executive and ManagerialWorker2Secondary 3 Clerical and Related Worker 3Senior Secondary 4 Sales / Service Worker 4Graduation 5 Farmer, Fisherman and Related Worker 5Post graduation 6 Production and Related Worker, Transport 6Doctoral7Operators and Labourer Worker not classified bythe above occupations7Professional degree (EngineeringMedicine, MCA, MBA, etc.)8Not employed 8Any other 9
*TYPE OF SCHOOL / INSTITUTION (refer item No.11)
GOVERNMENT: A high School is one that is run by the State Government or Central Government or Publicsector undertaking or an Autonomous Organization completely financed by theGovernment.ZILLA PARISHAD: A high School is one that is run by Zilla Parishad,MUNICIPAL: A high School is one that is run by Municipality or Municipal Corporation.PRIVATE AIDED: A private Aided School is one that is run by private educational agency and receives grantfrom Government.
Instructions to Candidates / Principal of school before filling up the Application Form forNational Means- cum-Merit Scholarship Scheme Examination; November-2011.
1. Application (s) must be submitted before the last date to the concerned District Educational Officer.2. The candidate must remit the Examination fee of Rs.100/-(OC/BC) and of Rs.50/-(SC/ST) in form of DD in
favour of “DIRECTOR OF GOVT. EXAMS. AP HYD” through SBH / SBI only and submit the Application
with Demand Draft.3. Candidates who secured 55% and above are alone eligible in case of OC/BC, 50% and above in case of SC/ST. OC & BC candidates secured even 54.99% and SC/ST candidates secured 49.99% are not eligible.The percentage should not be rounded off and treated as 55% or 50% as the case may be, Such candidates arenot eligible.
 
 
 
NATIONAL MEANS-CUM-MERIT SCHOLARSHIP SCHEME EXAMINATIONNOVEMBER 2011ADMISSION CARDTO BE FILLED BY THE CANDIDATE
:Master / Miss_____________________________S/o / D/o Sri._______________________________of (School)_______________________________of (Revenue Division Centre)_______________________He / She is allotted with the following 12 digit Roll Number:(to be filled by the O/o The
District Educational Officer’s office)
 Class State Code Year Dist Code Centre Code Roll No.3 4 0 1 1Date of Examination: Third Sunday in November month ie..,20-11-2011(from 10.00am to 01.00pm)Venue of Examination Centre(to be filled by O/o. the DEO)________________________________________________________________________________________________________________________________Signature of the Head of the School With SealScrutinized by(Office Staff)Signature of District Educational Officerwith Office SealSignature of the Invigilatorat the examination Centre*Signature of theCandidate in the MAT:
____________
presence of Invigilator SAT:_____________* If the candidate is Absent in two papers or in any one of the above 2 papers, an absent mark maybe shown against the subject by the Invigilator.
Passport sizephotograph attested bythe Head of the Schoolto be affixed withSchool seal
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