Page - 2/1

17.1.RollCode ! I I I I j 17.2.RollNo.l j I j j j I j I 17.3.PassingYear ! I I I I

16. Details of Matric/Oass x Board's-Roll Code I I I I I I Roll Number I I I I I I I I Passing Year I I I I I

15. Matric/Class X passing Board's Name .__I ___..I___._I __.____.___ ........ I___._I ___.____.__....,__.....___.____._._I __._I __,___.__.__...__.!___._I ~I

I I I I I I I I I

(Please tick- J) I Qualify~ng I ! Private I 14. Student Category I Regular I

11. Mobile No (Compulsory) I I I I I I I I I I I 12.1~~!:::ul~~) I I I I I I I I I I I I I 13. ~1~:~~~~r~~.0:p~~syor:~ I I I I I I I I I I I I I I I I I I I I I I I I I

changed leter on)

(Please tick- J) I Specify (if yes) I 110. Visually lmpaireds::J ED '--· -----'-·-----'· (Please tick-./)

9. Differentially abled

8. Caste category ( Please tick- .; )

jsc I I I sr I jGeneraq I jrnc I I I BC ! 7. Married

(Please tick- .; )

5. Father's Name (In English)

Full Sign11ur< or Studut

Green Backgroud)

(Plain White or light

4. Student's Name (In English) I I I I I I I I I I I I I .I I I I I I

I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I Male I I I Female I I I Transgender I I 6. Gender

(Please tick- .; )

Size-4.S cm X 3.S cm

Photograph

Colour 3. Name of the College

(In English) I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I

I I I I I I 1. Code of the College

ONLINE EXAMINATION APPLICATION FORM FOR INTERMEDIATE ANNUAL EXAMINATION, 2021

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Student's signature In Hindi Signature & Seal of Principal Page· 2/1.

Signature of Parent/Guardian Student's signature In English

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