Dayalbagh Educational Institute

Dayalbagh 282005
Admissions 2019-2020

Proforma for Award of CCA Marks

1. Application Number
2. Name
3. Father’s Name

A. Co-curricular Activity (Games, Cultural Activities …)

Member of a Team or Achievement as an Year Check Mark the Appropriate Box
Individual (Indicate Team or Achievement
School/ University State National
Title)
College / District Level Level
Level Level
1
2
3
4
5
6
7
8
9
10
11

2. NCC: A Certificate/ B Certificate/ C Certificate

3. NSS: Camp with 1 year training/ Camp with 2 year training

4. Scouting/ Guiding or Health or Social Camp:

Serial Description Year
No
1
2
3
4

1
5. Relevant Experience
Serial Description
1
2
3
4

B. Community Service

B1. Community Service at Pioneer Value Oriented Institutions

Serial Name of the Institution Nature of Service

1
2
3
4
5
6
7

B2. Community Service at other Places

Serial Name of the Institution/ Event Nature of Service

1
2
3
4
5
6
7

I certify that the above information is true to the best of my knowledge and in the event the
information is found to be incorrect, my candidature for admission may be cancelled

Signature Name: Place:

Date: