DECLARATION (to be uploaded at the time of online apply)

Scheme Write’ YES’ where applicable

National Talent Search (NTS) Examination

National Means Cum Merit Scholarship (NMMS) Examination

Session 20_ _ _ _ _ _ _ _

 Name of the student: __________________________ __ ____

 Category (UR/ST/SE/OBC) _ __ _ _ _ _ _ _ _ _ _ _ _ __ Whether Disabled: _ _ _ _ _ _
 Father’s name: ___________________________ _____
 Mother’s name: __________________________ ____ __
 Parental Annual Income: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Nos. of total children: _ _ _ _ _
 Residential address: Village _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
P.O._ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _Dist _ _ _ _ _ _ _ _ _ _
Mobile No. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
 Class in which the student read in: __________________
 Previous exam passed _ _ _ _ _ _ _ _ _ in the year _ _ _ _ _ _ _ _ _ _ from (name of the
educational institute) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
 Name of the present Institute :_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Village _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
P.O._ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ __ _ _ _ _ _ _
Dist _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ __ _ _ _ _ _
PIN Code: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
I do hereby declare that the above mentioned information are true to the best of my
knowledge.
Gender: _ _ _ _ _ _ _ _ _ _ _ _ Photograph of the
student

Date: ____________

Place: _ _ _ _ _ _ _ _ _ _ _ _
Signature of the Student/Applicant

Name of the Head of the Institution: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Contact No. ______________________
Institution Name _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _
Type of Institution (Government/Private) ____________________ ________
Whether under Govt. of India or Govt. of Assam: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
UDISE Code of the Institution: __________________

Seal & signature of the Head of the Institute