BELIEVERS CHURCH RESIDENTIAL SCHOOL Cee ae et Rampur Colliery P.O Katabaga, Brajrajnagar-768225 Jharsuguda(Dist},Odisha Phone +917077267262 [email protected] Website:www bersodisha org dg BVH OBO eaten KeeL Ne RAd abhie rece Passport Size Phot oh Online Application ore 1) APPLICANT INFORMATION | (Peas write CAPITAL LETTERS only) 1. Name of the Student: (as soon in the STD X mark ist) 2. Expansion of initials, ifany: 3. Gender (~): Male Female 4, Age: Years__ Month, 5, Date of Birth (DD/MM/YY): 6, Place of Birth: 7. Nationality 8, Blood Group: 9, Religion & Community: 4) Does the candidate belong to (7): SCO STO OBC O OEC O General (F SCISTIOBC/OEC produce community certificate) 10. Personal marks of identification: 1. 2, ----- DOCUMENTS TO BE SUBMITTED AT THE TIME OF ADMISSION ————~ 1g Transfer certificate Q Migration certificate. Certificate of equivalence Community certificate (only if applicable) (Candidates from universities/boards One passport size photograph of the student. other than in India) [Passport size photographs (one each) of father 1 Xerox copy of the mark sheet of classX_~ and mother Original mark sheet for verification {qOne passport size photograph of the local 1 Conduct certificate guardian (only if applicable) —--- —~ FOROFFICEUSEONLY ——; Name: Signature: Date: oon Group to which admitted: Page 1 of 4ll) PARENT DETAILS FATHER UL, a) Name jas in the Birth Centifeate ofthe applica MOTHER 1a) Name (as inthe Binh Cetfeate ofthe applicant) b) Occupation: ) Office Address: ) Occupation: 6) Office Address: 4d) Tel. No. (fice): ) Fax: 1) Mobile: 8) E-mail 12. Tel. No. (Residence): STD Code, 4) TAN, (fee 9 Fw 9 Mobile ma Tel. No. —____ 13, Annual income of the Parent: (2) COMMUNICATION DETAILS: 1d, Permanent Address: District: State: Country: Pincode: Tek: STD Code Tel. No Mobs 15, Address for Communication: Distt state: County: Pincode: Tet STD Code Tel. No. Mob: Page 2 of 41V) ACADEMIC INFORMATION 16. (@) | Nameof the School | Syllabus Grades Obtained in the qualifying exam last attended Followed Eng ss (©) Whether appeared for Global Aptitude Test (SGAD? Yes No O. (Wf ves, attach a copy ofthe score card) 17. (a) Subject offered Commerce Stream Humanities Stream English (Core) English (Core) ‘Accountancy Economics Business Studies Political Science Economics History Computer Science Computer Science (b) Choice of Stream in the order of preference: First Choic ‘Second Choice: V) GENERAL INFORMATION (Confidential) 418, Applicant lives with: Father Q Mother Q Both Q Other Specify) 19. Admission materials besent to: Father Mother BothO) Other (Specify) 20, Fees details be sent to: Father Q Mother Q Both Other Specify) 0 21, Checkifappropriate: FatherDeceased Q Parents Divorced Q FatherRemarried O Mother Deceased Q Parents Separated Q_— Mother Remarried 22. Does the pupil require Hostel facility? Yes 0 No O 23, Does the pupil require School Bus facility? Yes Q_ No If yes, write the nearest boarding point: 24. Details ofthe Brother/ Sister of applicant if studying in the school: Name: Standard: ‘Adm. No: Name: Standard: ‘Adm. No: Page 3 of 4Vi) GUARDIAN DETAILS [Only ifapplicaie] Aix the Photograph 25. Name of Local Guardian: of Local Guardian 26. Address iistriet State: Country: Pincode: Tel. (Residence) Office: Mobile: Signature of local guardian DECLARATION We father mother and local guardian of hraverread the rules and regulations of the school. We promise that our son/daughter will abide by them. We agree that we will not hold the school responsible for any untoward accident that might take place involving, ‘ourson/daughter. We will not put in any kind of compensation claim regarding such mishaps. Incase our son/ daughter violates any ofthe school/ hostel rules, the school reserves the ight to take any action against indiscipline, Also we promise that we will compensate for any damage caused tothe school property by our son/daughter. We further declare that all the information given above are trueand correct. Signature of Pupil: Signature of father: Signature of mother; Place: Date Alix the Alix the Photograph Photograph father other ° ‘of mother Page 4 of 4