12th Felicitation - 2017 FOR OFFICE USE

Keisham Sagei Foundation, Manipur 1. Rank ..

Regd. No. 185/MSR/2005 2. Below Rank ..
Affix one recent
Office : Hotel Tampha, North AOC Imphal 3. Non Provision
passport size photo .
4. Remarks .
NOMINATION FORM .

1. Categories of award (tick the appropriate box)

I. CLASS X - BOSEM : STATE LEVEL TOPPERS AWARD - 2017
II. CLASS X - BOSEM : KEISHAM SAGEI LEVEL AWARD - 2017
III. CLASS X BOSEM : MK IBOMCHA SAGEI LETTER AWARD - 2017
IV. CLASS X BOSEM : KEISHAM NINGOLGI MACHA AWARD - 2017
V. CLASS X CBSE : KEISHAM SAGEI LEVEL AWARD - 2017
VI. CLASS XII COHSEM : KEISHAM SAGEI LEVEL AWARD - 2017
VII. CLASS XII CBSE : KEISHAM SAGEI LEVEL AWARD - 2017

2. Particulars of the student

I. Class Board Roll no . SL MARK FULL
SUBJECT
II. Name of the student NO OBTAINED MARK
III. Fathers name .. 1
IV. Mothers name. 2
V. Address . 3
.
4
VI. School Name .
5
.
VII. Extracurricular / Co-curricular achievements 6
.
.
Total :..

3. Check points
I. Photo affixed? Y/N
II. Mark sheet enclosed? Y/N .
Signature of the student/ guardian
Contact No.
Date

4. Important time line, conditions and contact numbers

I. Last date of form submission : 26/07/2017 (upto 2 pm)
II. Date of felicitation : 30/07/2017, Veue : Hotel Tampha, Time: 11:00 am
III. Only the students who have passed from Manipur State in the year 2017 may apply
IV. Failure of form submission or non collection of awards in time will not be entertained
V. Result of the selection committee will be communicated on 26/07/2017 through SMS
VI. For further queries contact: VP: 9862213318, Secy : 9206130239. JS : 9856851601, Secy Edn
: 9436020998.