School Code – 45555

1. Name of Pupil ___________________________________________________

2. Mother’s Name ___________________________________________________

3. Father’s/Guardian’s Name ___________________________________________________

4. Nationality ___________________________________________________

5. Whether the Candidate belongs to Scheduled Caste or Scheduled Tribe ____________

6. Date of first admission in the school with class __________________________

7. Date of Birth (in Christian Era) according to Admission Register (In Figures)_____________________

(In Words) __________________________________________________

8. Class in which the pupil last studied (in Figures) __________________ (in Words) _____________________________

9.Schools/Board Annual Examination last taken with result _________________________________________

10.Whether Failed, if so once/twice in the same class ________________________

11. Subject Studied 1) _______________ 2) ______________ 3) _______________ 4) ________________ 5) _________________

12. Whether qualified for promotion to the higher class ___________________________________________ if so, to which class (in figures)
________________ (In words)________________________________________

13. Month upto which the pupil has paid the School fees/has dues ________________________________________

14. Any fee concession availed of :if so, the nature of such concession ________________________________________________

15. Total No. of Working days ____________________

16. Total No. of woking days present _____________________________________

17. Whether NCC Cadet/Boy Scout/Girl Guide (details may be given) ______________________________________________________________________

18. Games played or extra-curricular activities in which the pupil usually took part (mention achivement level there in) __________________________________________________________________________

19. General Conduct _______________________________________________________

20. Date of Application for certificate __________________________________

21. Date of issue of Certificate __________________________________________

22. Reason for Leaving the school _________________________________________

23. Any other remarks _____________________________________________________

Certified that the above information is in accordance with the School Register.