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National Institute of Open Schooling

Online Admission Form 2017-18 (Stream 1 Block I for Apr 2018 Exam)
NIOS COPY

Reference No A0217207970

Date of Registration:9-September-2017 Paste here your

Region : Pune
14:3:51 photograph of size
Candidate's 4 x 3 cm in this box
NOORJAHAN JAMADAR
Name only having Name
Father’s Name RAHAMAT of the learner and
Mother’s Name SHABANA the date of the
Photograph taken
Guardian’s Name
else the form will be
Postal Address ROOM NO. 31, 3RD rejected. Do not
FLOOR use pin or stapler
50/B DHAN CASTLE BLDG
CLARE ROAD, BYCULLA
MUMBAI
MUMBAI-Pincode : 400008 Your Signature
District/State for MUMBAI
AI MAHARASHTRA
Aadhar No 790356599988
Subjects English (202), Economics (214), Mathematics (211), Business Studies (215), Science and
Offered Technology (212)
AIs (study Centre) Selected are 1. DEPT OF ADULT & CONTINUING EDU &EXT (110051) 2. St.Andrew's
High School (110003) 3. BHARAT EDUCATION SOCIETY'S (110080)
Date of Birth: 15-May-2000 Telephone: 9323393532 Mobile: 9820587911

Gender: Female Category: General Disability: Not applicable

Course Applied For: Secondary (10th) Medium: English Nationality: Indian

Admission under Dual enrolment: NO Email: mohid.cutterwala@gmail.com Previous Qualification: IX

Mode of Payment: Debit Card -->Admission Fee: 1260.00 + Late Fee: 700.00 + TOC Fee: 0.00 = Total Fee: 1960.00
Bank Transaction Reference No: CTX1709090834022309909
Transfer of Credit: NO ->Enrolment No: Year of Exam: 0 -> TOC Board:
Marks Obtained
S.No. Subject Code of NIOS
Theory Practical Total

1.

2.

3.

4.

Declaration by applicant : I hereby declare that I have read and understood the conditions of the eligibility. I have furnished all the necessary documents and information
correctly. I understand that my candidature is liable to be cancelled by NIOS in the event of any information or document is to be found misleading or incorrect at any stage. I

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accept the admission rules laid down by NIOS.

Signature of Parent/Guardian _____________________Date : _____________Signature of Candidate : ______________

Enclosures (Please (Tick) as applicable) :
1. One Printed On-line filled in application form
2. One recent colour passport size photographs pasted (NOT TO BE STAPLED) on the printed application form. The Photograph should have name of the Learner
and the date of photograph taken else the form will be rejected
3. Attested copy of proof of Date of Birth
4. Attested copy of Certificate for SC/ST
5. Transfer Certificate from the last school attended
6. Self Certificate regarding educational qualifications
7. Attested copy of Marksheet of Class X Board Examination
8. Certificate from the current Employer for Ex-Serviceman
9. Certificate from a Government Hospital for a handicapped person
10. Original Failure / Compartment Marksheet (not laminated) of Class X or XII for TOC
Note : IF TOC Board marked with (*Other) is selected then the Result should be available on the Cocerned Board Website or Learner has to get the TOC Data verified from
the Concerned Board for grant of TOC as per NIOS Norms.
11. Address Proof as per the Annexure mentioned in the Admission form

To be signed by the Candidate if he/she wants to get admission on the basis of Self Certificate
Self Certificate(to be signed by all those not enclosing School Leaving Certificate). Certified that I have studied enough to be able to
pursue Secondary level Course

Signature of the Candidate

For Office Use only

Dated: ___________________ Checked & Verified Signature: _______________Name of the Official
______________
Reference No: A0217207970 Enrolment No.:_________________________
Generated By (Name): ____________________ Signature:_______________

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INSTRUCTIONS TO BE FOLLOWED AND RETAINED BY THE LEARNER
1. Read the instructions carefully before form is being dispatched to NIOS.
2. Send the NIOS Copy of Online Admission Form ) along with the required documents and bank draft of requisite fees, in case, fee is paid through Bank Draft within 5 days to
the NIOS.
3. Keep photocopy of the NIOS Copy of Filled in online admission form with you for all future reference.
4. For dispatch of the form to NIOS, paste the address slip on an envelope; keep the Office Copy of Online Admission Form alonwith enclosures safely in the envelope.
a. Laminated Marksheet will not be accepted for TOC
b. The CBSE Candidates of year 2010 onwards may enter the Subject Grade points for TOC
5. Please note this Reference Number A0217207970 carefully for all future correspondence and monitoring the status of your candidature.
6. Kindly note the following in case of confirmation of admission:-
(i) Enrolment Number will be issued through E-mail and on the Net through Public Comment.
(ii) I-Card will be dispatched at your address.
(iii) The PCP of Stream I (II Block) will commence at your allotted AI from 1st Sunday of May 2017.
(iv) Submit your TMA (available on Net) at the allotted AI as per schedule.
7. The first examination for Stream I (I Block) will be held in Apr 2018.
8. Deposit Exam fees during December for Apr exam and in June for October Exam.
9. Only one Form should be send in one envelope.
10. First Exam in April for Reference No Starting with "A" and first Exam in October for Ref No Starting with 'N'
11. Contact numbers are : 18001809393
12. For any queries Contact Learner Support Centre at 18001809393.
13. The Study Material will be delivered to you at your address provided by you during the Registration free
of cost. Do not accept any VPP Parcel from anybody.
14. The Learners who are paying the Fee through online will get Study Material before the confirmation of
the Admission at your adreess provided by you during the Registration free of cost. The confirmation of the
Admission will be done after due verification of the Documents and as per the NIOS Norms.

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ADDRESS SLIP
------------------------------------------------------ CUT FROM HERE AND PASTE ON THE ENVELOPE----------------------------------
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Application for On Line Admission Stream 1 - Block I (2017-18)

Reference No: A0217207970

To,
National Institute of Open Schooling
Regional Centre - Pune
From: C/o. Indian Institute of Education,
128/2, J.P. Naik Road, Kothrud, Pune-411029
(Maharashtra)
NOORJAHAN JAMADAR,
ROOM NO. 31, 3RD FLOOR50/B DHAN CASTLE BLDG
MUMBAI
MUMBAI400008

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