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BSNl CORPORATE OFFICE

1. Name & Designation 2. Whether- belongs to SC/ST/OBC category 3. Office Address (Where working) 4. Basic Pay (Pre-revised/Revised) (Attach latest copy of the Pay Slip) 5. Basic pay of the spouse and office address: (If spouse is working in BSNL) 6. Whether the ward is entitled to any Relaxation in marks, if so the details thereof:

B.
1. 2. 3. 4.

DETAILS

OF STUDENT

Name of the Student Relationship with the applicant Date of Birth Whether the child is Physically Handicapped: (Attach copy of the medical certificate) 5. Class in which student is studying 6. Name of the School 7. (a) Marks obtained in previous class

(b) Grades obtained in previous class & equivalent marks (equivalent marks obtained in 0/0 should be clearly indicated) (Attach copy of Marks Sheet/Report Card duly Attested/certified by any executive of BSNL) I declare that the above particulars are true and complete to the best of my knowledge and belief. Signature Tele No. Dated: Certified that the entries made under 'B' are correct _ of the applicant

Signature

of the Head of

School (With Rubber Stamp)