NAVODAYA VIDYALAYA SAMITI

JAWAHAR NAVODAYA VIDYALAYA SELECTION TEST

LATERAL ENTRY-CLASS IX - 2022-23
APPLICATION FORM

REGISTRATION NO.: 12021339

State MADHYA PRADESH District BETUL

Name of the Candidate CHITRA DWIVEDI
Mother's Name ARTI DWIVEDI Father's Name HEMANT KUMAR
Name of the Guardian - Relationship with -
Guardian
Nationality of the INDIAN Date of Birth 01-Nov-2008
Candidate
Present Postal Address Q NO 11 TYPE 3 CONGRESS NAGAR PATHAKHERA DIST BETUL MP : 460449
Telephone - Mobile No 8050291445
Gender FEMALE Category GENERAL
Marital Status UNMARRIED Identification Mark A MOLE NEARBY RIGHT LEG
KNEE
Disablility, if any NO

Details of school where candidate is studying his/her Class VIII during 2021-2022

Name of School KENDRIYA VIDHYALA SARNI BETUL MP

Recognized / Not Recognized RECOGNIZED
District & State BETUL & MADHYA PRADESH
School Location(Rural/Urban) URBAN
Month & Year of Joining 01-Apr-2021
Expected Month & Year of Passing 31-Mar-2022
Medium through which candidate is studying in Class VIII ENGLISH

CERTIFICATE BY CANDIDATE/PARENT/GUARDIAN
Certified that the information given above is true to the best of my knowledge and belief. In case any of the information given
above is found incorrect, I will abide by the decision of the Samiti

Signature of the Parent Signature of the Applicant