DECLARATION FROM THE STUDENT ENROLLED UNDER JAI BHIM

MUKHYAMANTRI PRATIBHA VIKAS YOJNA

I ------------------ ----------------------------S/o D/o--------------- -------------------have passed my 10 th class from

------------------------------and 12th classes from ----------------------------------------------schools located in Delhi and I have
Secured prescribed % of marks in the qualifying examinations for the course as per the scheme and am eligible for
availing coaching facility under the guidelines of the scheme “ Jai Bhim Mukhyamantri Pratibha Vikas Yojna”

and

belongs to--------------------- (SC/ST/OBC)Category and have submitted valid Caste certificate bearing number
-------------- and Income certificates bearing number -------------------------- issued by the Office of the District Magistrate,
Govt. of NCT of Delhi to the empanelled coaching institute-------------------------------

Or

belongs to General Category & have submitted valid EWS certificate bearing number -------------------- issued by the
Office of the District Magistrate, Govt. of NCT of Delhi to the empanelled coaching institute-------------------------------

It is again certified that particulars in the enclosed student authentication form furnished by the coaching institute are
correct including with respect to Date of commencement of coaching and number of days attended by the
undersigned.

Or

A. If, there is some objections to rectifications required in the details furnished by the institute, Please specify the
same below:-

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B. Provide your input as regards to quality and adequacy of the coaching provided in the space below and if need be
also on a separate sheet duly signed by student and with heading “ My input as regards to quality and adequacy of
the coaching” .

Name & Signature of the student Name & signature of the parent
Address:----------------------------- Photo ID of the parent is enclosed.