Rs.

250/-

Form No. .......................

JMIWDAF2013

JAMIA MIDDLE SCHOOL

Affix your recent photo

(size 2"x1.5") self attested.
Photograph should be
pasted with gum and not
stapled or pinned.

JAMIA MILLIA ISLAMIA

JAMIA NAGAR, NEW DELHI - 110025

2013 2014

Application Form
Reg.No.

Read the Prospectus carefully and Instructions printed overleaf before filling up this Application
Form. Incomplete Form will not be considered.
1.

Application for Class:

Category

Male

Female

(See Code at the back)

2.
3.
4.

Name of Candidate (in block letters):

Father's Name

Mother's Name

5.

Name of guardian (if any)

6.

Nationality : ...........................................

7.

Annual Income of father or guardian (if father is not alive)

8.

State to which Candidate belongs

:..........................................................................................

9.

Local Mailing Address (if any)

10

Permanent Address :

.....................................................................................................

............................................................................

.....................................................................................................

............................................................................

.....................................................................................................

..................... State

Pin ....................... Phone No...................................................

Pin ................... Phone No ..............................

Nearest Railway Station (for Railway concession)

11.

..............................

Date of Birth (in words)

: .......................................................................................................................

12.

Year

Place of Birth : District : State :

13.

Last Examination Passed

14.

Institution last attended

:......................................................................................................................................

(in figures) :

15.

Day

Month

Year

Institution

Result

Grade/Percentage

Bank Draft No. ........................... Date ................. Drawn on Bank ............................................... Rs. ...........................
(only for downloaded forms)
.......................................................
Signature of Applicant

Date
.........................

-----------------------------------------------------------------------------------------Acknowledgement Slip

Form No. .......................

Received Application Form from for class on

Reg. No.

Dealing Asstt.
P.T.O.



INSTRUCTIONS
Note:
1. Category code should be given carefully. Incorrect proclamation of the category shall lead to immediate cancellation of
form/admission.

CODE

CATEGORY

GE

General

Muslim

MW

Muslim Women

MO

Muslim OBC

MT

Muslim Sheduled Tribe

PD

Persons with Disability

KM

Kashmiri Migrant

2. Do not attach original copies of certificate of marks-sheet etc. with the form.
3. If the application is sent by post, the candidate should collect the Acknowledge Slip before the Draw of Lots.
4. Recent self attested photograph should be pasted with gum and not stapled or pinned.
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------

DECLARATION
I, hereby, solemnly declare that:
i)
ii)

The information given in the form is true to the best of my knowledge and belief, and
I have read the rules printed in the School Prospectus and agree to abide by them and
accept the changes (if any) made therein at a later stage.

Date

Signature of Father/Mother/Guardian

Signature of Applicant

CERTIFICATE
(For Jamia Employee's son/ daughter only)
Certified that Mr. / Mrs. ..............................................................................................................................................................................
(Name of employee)
father/mother of ................................................................................................................ is an employee of Jamia Millia Islamia and
(Name of candidate)
has been working in ....................................................................................................... as .................................................................... on
(Name of candidate)
permanent / probation / temporary /adhoc / contract / daily wages basis since .................................................

.........................................................

..................................................

Counter Signature

Head of the Deptt. / Office / School

S.O.

Office Stamp

(Medical Section, J.M.I

Schedule of Lottery Draw 2013-2014

Jamia Middle School
Class
II

Date

Time

th

15 April, 2013

02:30 p.m.

th

02:30 p.m.

th

02:30 p.m.

16 April, 2013

VI

17 April, 2013

Place
Multi Purpose Hall,
Sr. Secondary School,
JMI