DELHI PUBLIC SCHOOL

(SAIL TOWNSHIP, P.O. DHURWA, RANCHI-834004)

Phone-0651-6452405, 6452406, 2441176, Fax-0651-2440707,
Affiliated to CBSE, New Delhi, Affiliation No.-3430053
Managed by The DELHI PUBLIC SCHOOL SOCIETY, NEW DELHI,
(Registered Under the Society's Registration Act. 1860)
E-mail : info@dpsranchi.com, Website: www.dpsranchi.com

Reg. Form No.: DPSRXI-19-11100111 Class-XI

APPLICATION FOR THE ADMISSION IN CLASS-XI (2019-2020)

Stream: PCM Subject:Computer Science Board: CBSE
01. Student Id : 11100111
02. Payment Reference No. : DUA3778306
03. Name of the Student : SHIBAM CHATTERJEE
04. Date of Birth : 31/01/2003

05. Blood Group : B+

06. Gender : MALE

07. Religion : HINDU

08. Aadhaar Card No. (UID) : 841934933290

09. Name of the Present School : HOLY CROSS SCHOOL

Signature of Candidate
10. Category : GENERAL 11. Nationality :INDIAN
12. Proficiency :
13. Medium of Instructions : ENGLISH
14. Is there any blood relation (brother/sister) are presently studying in this School? :
a) Name, Class/Sec., Admn.No. : ,,
b) Name, Class/Sec., Admn.No. : ,,
15. Parent Details
a) Father : SUKHENDU CHATTERJEE
Educational Qualification : INTERMEDIATE
Occupation : SERVICE
Designation : SR.MINING ASSOCIATE
b) Mother : MOHUA CHATTERJEE
Educational Qualification : GRADUATION
Occupation : HOMEMAKER
Designation :
16. Address & Communication
a) Correspondence Address : C/O SUKHENDU CHATTERJEE, SR.MINING ASSOCIATE,SFK/4,
NEAR KALI MANDIR, HOUSING COMPLEX, WEST BOKARO D
Country India State JHARKHAND
City RAMGARH Pin Code 825314
b) Permanent Address : C/O SUKHENDU CHATTERJEE, SR.MINING ASSOCIATE, SFK/4,
NEAR KALI MANDIR, HOUSING COMPLEX, WEST BOKARO
: Country India State JHARKHAND
City RAMGARH Pin Code 825314
c) Phone No. :
d) Mobile : 9031789788
e) Email ID : cpuja4@gmail.com
17. Physically challenged : NO
Exemplary Academic Performance : No

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 DELHI PUBLIC SCHOOL
(SAIL TOWNSHIP, P.O. DHURWA, RANCHI-834004)
Phone-0651-6452405, 6452406, 2441176, Fax-0651-2440707,
Affiliated to CBSE, New Delhi, Affiliation No.-3430053
Managed by The DELHI PUBLIC SCHOOL SOCIETY, NEW DELHI,
(Registered Under the Society's Registration Act. 1860)
E-mail : info@dpsranchi.com, Website: www.dpsranchi.com

Reg. Form No.: DPSRXI-19-11100111 Class-XI

* Submit your application to the school office along with the photocopy of SBI Payment
Reference Slip, Birth Certificate , Aadhaar Card (UID) and Supporting documents of
Exemplary Academic Performance
Declaration
I agree to abide by the rules and regulations of the institution. If any information of declaration furnished by me proves to be
false, my ward’s candidature may be cancelled at any stage.

Date :
Place :
(Signature of Parent/Guardian)

---------------------------------------------------------------------------------------------------------------------------------------------
[FOR OFFICE USE ONLY]

Receipt No. : ................................ Date : ...............................Form No.DPSRXI-19-11100111

Year of Appearing (Class-X) : 2019

ACKNOWLEDGEMENT SLIP/ADMIT CARD

(This Acknwoledgement slip will be treated as the Admit card for Admission test)

Name : SHIBAM CHATTERJEE

Student Id : 11100111

Stream : PCM Subject : COMPUTER SCIENCE

Date of Submission : ..................

[Authorized Signatory]

N.B.: Please collect the ACKNOWLEDGEMENT SLIP from the office at the time of submission of the
application form.

Kindly submit the Application form in time between 09:30am to 12:30pm.

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