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APPLICATION FOR OBTAINING PERMISSION TO OPEN NEW PRIVATELY MANAGED PRIMARY / UPPER

PRIMARY SCHOOLS

A. School Details :

1. Name of the School :__________________________ 2. Medium of Instruction 1 : ________________


3. Academic Session : ___________ 4. District : ________________ 5. Block/MPL/NAC : _______________
6. Postal Address : ________________ 7. Village/ City : ____________ 8. Tahsil : _______________________
9. Pin Code : _____________________ 10. Phone no. : _____________ 11. FAX No. : ____________________
with STD Code
12. E-Mail ID : ____________________ 13.: Nearest Police Station : ______________ 14 : School Type 2 : ______
15 . Name of GP : ________________ 16. Ward No. : ______________ 17. UDISE Code : ________________
Codes to be used above :-

1. Medium of Instructions : English / Odia / Telgu

2. School Type : Girls / Boys / Co-educational

B. General Information :
1. Year of Establishment : _______________
2. Whether the School is managed by a Trust/ Society/ Managing Committee/Others : ________________________
3a. Name of the Trust/ Society/ Managing Committee/Others : _________________________
3b. Registration no. of the Trust/ Society/ Managing Committee/Others : _________________________
3c. Period to which the Registration is valid ( MM-DD-YYYY) : _____________________ / Life Time
3d. Source of Income to manage the School : _______________________
4. Name & Address of the Managing Trustee/President/Chairman of the School -
a. Name : ________________ b. Designation : __________________ c. Address : ________________
d. Office (Ph) : ____________ e. Residence (Ph) : ________________ f. Mobile : _________________
g. E-Mail ID : _________________________
5. Number of schools in the GP/NAC/Municipality: _______
6a. Name of the nearby Primary School: ____________________________________
6b. UDISE Code of the nearby Primary School : ______________
6c. Approximate distance of Primary School (in KMs): ___________
7a. Name of the nearby Upper Primary School: ____________________________________
7b. UDISE Code of the nearby Upper Primary School: ______________
7c. Approximate distance of Upper Primary School (in KMs): ___________
8. What will be its effect on the enrolment of existing school if the permission will be given to the proposed school:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
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9. Name of the feeder Primary school (In case of opening of Upper Primary school) :______________________
10. UDISE code of the Feeder School: ______________
11a. Whether the School has its own land and building : Yes / No
11b. Upload the Document related to Draft of Title and Possession issued by Tahasildar: <Upload document>
11c. Area of Action which the School is proposed to be located : RURAL / URBAN
11d. Number of Pucca Rooms of Standard size (If the construction of building is completed): _____ (in number)
12. Need of opening of school in that locality: ____________________________________________________
_________________________________________________________________________________________
13. Upload Authority Signature: <Upload JPEG / PNG format file>
14. Down load and Upload the declaration: <Upload the signed copy of the declaration>
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INFORMATION SHEET
UNDER TAKING

In pursuance of Govt. Notification No. 2950/SME Date 21.02.2017, I _________________ Secretary of


____________________________ under ____________________ Block in the District of _________________ give this
undertaking that in the event of permission being granted.

1. Adequate Financial provision shall be made for continuance and efficient maintenance of the institution.
2. The institution shall be located on the land specified in the application and that such land shall located in
sanitary and healthy surroundings.
3. The Building, play ground, furniture and other facilities shall be provided in accordance with the provision of
this Act & Rules prescribed therefore.
4. All the requirements lay down by the Act., the Rules and orders if any issued there under shall be compiled.

Countersigned Signature of the School Authority


Secretary

President (Full Name and Address)


(Full Name and Address)