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 Application lorm
National'l'alcnt Scarch E\anlina(ion. 2020-21
for the Students Studying in lbr Class X)
i I(ad ll. rnlltucliotr .aretrlli gi!.n helorc filling ll,e applicari(,n fiht
iilhe rc':! :3g.
You may lakc lhe help from your leachcr/parenl fo. filhrg up lhc npplicalion form.
rl I

Space lbr lhe lhotograph

Ewlnation:
Datc of
Nme & addr€ss ofthc ag6cy for con{lucrng N-lS Examinarotr
- Ndne ofrheSrareUT
(\l'herc the @didat€ is 5udyitr8 in class X as a regular $udmo:
- Nane of tbe cxaminati6n .alr lhe Phorog.aph should bc
r$]]"lecandidarestudyrne rn.la. X $li\e\," appc!.,nnan' .rdors.C \ rhe lread o!
- Applic.iior f.., ifany (Ene NIL if rh@ rs no !i!). Ihe lnsUlur,on,Oactrcd

School Drse Codc

r

Stnt. t.evel I I digit RollNumber -l-

I til
Codc Year Serial No (Ofiice fill) l)atc ofbrdh

rTn
State Centre Codc Class

Drl_llx
1()

ll- Date Month

l. Nrmr oflhe ratrdidate (Do not write Miss/Mriler)

2. Falhrr's nane lDo not write Mr./Dr./Prof)

L

3. Mothrr's Nam. (Do not write [tr./Dr./Prof)

4 Sex

Malc
1
tr trtr 5. Area

Female Rulal Urban

to lrtich candldates res,des 6 Caste
1

General
tr trtrtr
category ofcandidate

OBC SC Sl EWS
(Non C4.my LrJ.4
7
trtrtrtrtrtr
Disability status

BLV DII LD AID MD

R.r.r ov.rl..a for d.oib of.od6
NONIj

6b. Do you belong lo OBC Carcgory (Ple"s. Refs dciails dvcn on www nck.nic ir/nsslanel/cntrallisBhteview aspc) ofCentral lisl?

(Please entlosc a copy of thc relevant certificate in supporl ofinformation al Sr. No.6 &7)
8 Poslal addrcss oflhe candidale for correspondence (Do not \lrile fathcis or your name)

II Pin Code
9 Name and address ofthe School/lnstiuion in which studying at Class X levcl

II
I'rn C

l 0 l ype of th€ instilution in which studying at Class X (see definilion ovcrleal> ) I I Arca in whrch thc school rs locatcd

[] co,r E] r-o""r noay f:-l 4 L Rurr (.;rban

l0a. Arc you Sludent of Kendriya Vrdyalaya / Navodaya V idyalaya! Ilyes, wrile 1 Il No. \vrite 2

l0b. lfyes, wntc tir 1 Kendnya Vidyalaya 2 for Navodaya vidyalaya

l2 Mcdium ofexamination(a)at the statc Level (b) rt the NCLR I Lrvel

ll Fathcis cducanon 14 [alher's Occupanon l5 Mother's cducation 16 Moth€r's Occupalion

l7 No olfamily memb€rs living in th€ house

20 At what no is the candidate among his/her
18

brothers and sist€rs

No ofbrolhers
II
21. Parcnlal annual incomc
1 2 3 4

Upto 2.00.000 2.00,001 to 1.00,000 1.00,001 io 5,00,000 5,00,001 to 10,00.000 More rhan 10.00.000
?2 Ielcphonc
S I l) Codr
l4 l,fobilc
ll)o not l.rwrbis colurn blant)
Io De fill.d by the flead o{th. tnstitutio./Gazett.d Olficer
Ccnified that:
(l) Vaslcr/Mrss.. rs a rcgular sludcnt ofrhis School/lnslitulion arld hc/sh€ has

secureri f--.l--l "/o m.rks in lhe class lX annualexamiralion, i. c . wncn he/shc \as promolcd l-rom class I\ 1(J Class \
He/She

has sccured marks oul ot

(2) Thc pa(iculars given by him,4rer in the applicatron tlom have bcen veriticd and tbund 1n onlcr.
( I) Masrcr/Miss belongs io schcduted castdschcdulcd rribc caregort ds pcr the
records mainhjned in the lnstitution.(io be fill€d for SC/ST candrdat€s only)

signature of the Headhaster/ Headmistress/Gazdted ofiicer

Withseal
Srsrrr r. ol thc cand(lalc (5ee Lnn.uctions Overleaf )
de{ rgs d frq
r. qs ncrFrd foqr qrdr t fu *7Eq6 ftqmq,/€rerT ot,/sT
ffi fufl?ff t r fusrpff i oen sff q f-F cidcro sio cT.a- Gti * r ftspff i oa
5-f-rf qr( f6i f,1
z. fuqpff d grr cnifi q* t {t .r$ qrrort Wtrqr s.q t r

s. */gqrt {ir.sr Ef, agofi. erl-w+wft +1 (fiflrdq d

M d :ryvr*) u6r7ar* tr
ft{16
TiFn l.gq d gwrr*

g{r+i6 d 6wren

€Ed qrad d rwnrs

 ( odine I'lan

R.ed instruction crrcfrlly b.fore filling rp lhe Applicaliofl }-orm.

I Usc only Blue or Rhck Aall Point pen. WRITIj lN CAPIIAL LE r]l;RS l)o not nurli or *rirc outside lte bo\cs
2 Lqve one box bia* between lso {ords Lnn n )..ou namc and. or address silhrn th. sp.cc p.o'idcd ior ir Pleisc sd.\amplear gnd' bclo*
3 Cross(x ) only one of d]e approprinl€ boxcs in ile,ns nos. 4. 5 .6. ?. I0-lla.d2l.
4. Plcase *rite code numb6 in ncms nos 12, ll,
I4. l 5 and l6 as givcn overleaf
5. lr is lhe responsibilny otlhe candidaE and rbc principal ofthc sclool !o deposit the filled in fom wilh lhc slate conemed Olficcr beforc lhc last
date No rcquBr for.ondoning delsv in submision *illbe dlcnanrcd rhcthcr i! is duc to thc laulr ofrhc Candidarc or rhe Headmaster/Pnncipal
ofliellcr inslitutiotr
6 Incomplete or defmsive applicntions are liablc to bc rcjecled.
7. 4% for Physicrtlt chrtlogcd cmup of Stud.ots, with benchmark disabililies of which. onc p€r cent each shall be reserved for
persons with b€nchmark disabilities under clauscs (a), (b) and (c) and one per ccnl for pcrsons wilh bcnchmark disabilities under
clauses (d) ard (c) name,y:

(.) blitrdr€ss rod lo'w vision (BLVli

(b) drrfrnd herd ofhearing (DlI)i
(c) .nd muscular
locomotor disability inctuding ftrebrsl pilsy, l.prosy cured, dlv.rfism, acid attack victims
Dyslroply (LD);
(d) autism, intcllcctuel disab;lity, spccific learning disebility ind mcntal illnsss (AlD);
(e) nuhipl€ disrbilitics from .motrgst p.rons under rhus.s (.) to (d) ircluding de!t- blindness in th€ posts
identified for e.ch disabiliti.s' (MD)
EIample forwriting Name rnd Addrcss.
ijalhe.s Name O Pi (; U I

Postal Addr€ss: do oot rry to \rrile completc rddress in one line. tsrcal it ippropri,ticly lts sho\!n bclow
I 5 6 M o ti N I R o D
Stale/L'[

IIITII
Rryion Code

C LI E \ N I PIN
North
East
Arunachal Pradesh ]l
ll
I
Medium ofExamination
Refer to item 12
t Education ofFather or Mothcr
(Refer to item Nos 13 & 15
Manipur
Meghalaya
1l
L]
Mcdium ol Codc Iducation Codc ffi
Ixamination Nagaland t6
Assamese lt No Formal Education I
Srkk im l7
Rangla 12 Up to primary 2
,ripura l8
hnglish t3 Upper prioary
East A& r.\ Islands l9
Cujarati l't Secondary -t
Iindi Illhar 20
I I5 Scnior secondarv 5
Karxlada
Maralhi
!lalayalam
l6
t1
I8
(iraduation
Post graduation
Doctoral
6
1
8
l
Jharkhand
Odrsha ,,
2t

I
2l

+
West Bengal
Orivn l9 Professional degrce I 9 I
Nonh Chandigarh 1.1
(Engineering,[,aw.
Medicainc, MCA, BA,etc)
- Dclhr 25

Punjabi 20 )6
I amil 21 Ilarlana 11
I elugu 21 Ilimichal Pradesh ts
Urdu 23 Puntab 29

Raj,rsthan l0
I.rh.r',
(rcf.r io
ino!h.r'3 ncop.rion
ir.n No5l,r& 15)
tl @
lunamkhandlxl
wcsr I Chhalrssarh I Jl
!LI I

E\qive and MrnaBrial

I Daman&Dru I la I

I I D&N Haveh I 15 I

t t--
l6
Prcdudion and lraospon

al ls
I
\,1adh!a l,.adcsh
L

l9
South ,10
'Trp. ofS.tooul6rnutior. (Er.rr. n.m o.l0)
f-
COVERNMENT A Gorcmm€.r *h@l i. rld wnich ii tun by rhc Sht
covem,ftni or Pxblic Sdor undfialins or
Orgai?lion 6mpld.ly r..nccd by
d Atro@mous
rh. Covoodr
-t il
42

I-OC L BODY A Ldal Body School t rh.r *hich is Nn by Panchayari R4

!.d lff.l My insritulio6 s.h r! zib Parich.d, municipal 1l
Corporariotr Municipal Coonnie. Norilicd 4.6 I arnrl \adu
Commirte and C..lonnmr Bo.!d
Tclangana
|RMTE AII)ID A privalc aidcd schel is rhit,hich is tun by an rndividual ll
or a pn%r. dslnianon lnd reiv* g! iom 11

-lovedfrenr or l@l body

PRMTI: UNAIDED Privare Unaidcd Sch@l u lhar which G manas.d hy an
individlal .r i Dnlate organiz2rion and dB d iei!. any

lrot f'om sovemdcnt o,1@l body

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