LIST OF DOCUMENTS TO BE SUBMITTED

1. DOWNLODED REGISTRATION FORM ( FIRST 4 PAGES)

2. Downloaded marksheet of Class X countersigned by Principal of the school.
3. Copy of Birth Certificate
4. Nativity Certificate or Residential Certificate (Certificate must be in the name of the
Child)
5. Service certificate from the competent authority by Govt Service holders
a. Service certificate if parents are Govt employees in the format provided along
with signature of the DDO.
b. Copy of First page along with transfer details mentioned page of the Service
Book
6. All transfer orders copies to be submitted
7. Recent Salary Slip of the employee
8. Certificate from the Employer in the Given Format
9. Self- Declaration Format(Format Attached)
10. Undertaking by the parents (Format Attached)
11. Valid Caste/Community Certificate (for SC/ST/OBC)in the name of the Child ONLY
12. Proof of Residence (Rent Agreement/Aadhar Card/Voter ID/Bank Passbook/Gas Card etc)
13. Affidavit for Single Girl Child from First Class Executive Magistrate in 100 rupees
stamp paper
14. Copy of Aadhar Card of the Child
15. Copy of Aadhar Card of the parents
16. Copy of Blood group certificate of the child.
NOTE:
1. Candidates are required to put all documents in a single envelop, write their name
and contact no in the Cover of the envelop and submit it in the drop box kept in the
school premises.
2. If selected for admission ,all the above documents in ORIGINAL will be needed for
verification along with ORIGINAL TC for admission.

ALL THE FORMS AND FORMATS FOLLOWS

 KENDRIYA VIDYALAYA NO.4, BHUBANESWAR

SESSION 2023 - 24
Registration Form for Class –XI
Fresh Admission (Outside KV No 4,Students)

(Admission Subject to availability of seats as per KVS Admission Guidelines 2023-24)

Registration No. /S.No Stream: Commerce

1) Name of the Applicant (in block letters)

2) Father's Name
3) Mother's Name
Recent
4) Date of Birth( in Figure)
Passport Size
(in words) of Photo of the
Applicant in
5) Address / Res:
school uniform
Permanent: -
6) Service Category Office Address
Cat: 1 Central government permanent employee.
Cat: 2 Permanent Employee Autonomous departments under central govt.
Cat: 3 State government permanent employee
Cat: 4 Permanent Employee Autonomous departments under state govt.
Cat: 5 Private job, business, farming, other work
(Attach Service certificate issued by competent authority or office for Govt employees only)
7) Telephone/ Mobile No. WhatsApp No
8) Email ID
9) Please give following details and Enclose all related documents
Aadhar Card Number: Blood group
10) Do you belong to SC/ST/OBC (Enclose Certificate)
11) Achievement in Games & Sports/Scouting &Guiding/ NCC/ Adventure activities with level in state or national
(attach copy)
12) Details of qualifying Exam. passed (Class X) Board Year Roll No. Appeared
(Regular/Private) School name with Address

13) Domicile State Mother Language

 - (2) -

14) Details of the grade & grade points obtained in qualifying Exam. (enclose scanned copy of Mark sheet)

S.No. Subjects Marks Percentage Subject Percentage

1. English
2. Hindi/ Sanskrit Science
3. Mathematics
4. Science Maths
5. Social Science
6 Percentage Marks in Aggregate Average
(TOTAL) (Science+
7. Any additional subject if taken Maths)
8. Total

15) Please tick (√) in appropriate box for stream/Subject choices in which admission is sought provided below:
a) Commerce:
i) English Core, Business Studies, Accountancy, Economics, Hindi ( )
ii) English Core, Business Studies, Accountancy, Economics, Maths ( )
iii) English Core, Business Study, Accountancy, Economics and Informatics Practices ( )

Note: 1. Attach self-attested scan copy of all related document.

UNDERTAKING

I ………………………………………………….... (Student) and……………………………………………………..…. (Parent) hereby give

undertaking that the above given option for Stream and Subjects for Class- XI has been offered by us after due
consideration and that our decision is final in this regard. We also submit that no request regarding change of
stream or/ and subject(s) will be made by or on behalf of us in future.
Date……………………
Place………………………

Signature of the Student Signature of Parent

………………………………………………………………………………………………………………………………………………………

Acknowledgement receipt (For office use only)

Received Admission form SL. No. from for admission in Class XI.

Date………………… Signature of Clerk

NOTE: THE TOTAL FORM HAS TO BE FILLED AND SUBMITTED THE HARD COPY BY 7TH JUNE 2023 11AM
 केन्द्रीय विद्यालय क्र.4 भुबनेश्िर
KENDRIYA VIDYALAYA No.4, BHUBANESWAR
(Tel No. 0674-2721298, E-Mail:[email protected] web site: no4bhubaneswar.kvs.ac.in)

iathdj.k प्रपत्र / REGISTRATION FORM Annexure VI

REG. NO.

क्रम सं /S.No. िर्ष/Year 2022-23 2023-2024

Photograph of the
child
पंजीकरण के ललए कक्षा Registration for class……………………/ Stream……………………….(Put tick mark in appropriate box)

1.विद्यार्थी का पूरा नाम (Passport size)

Name of child in full (in Capital letters)………………………………………………… Sex M F

Day Month Year

2. जन्द्म तिथर्थ (अंको में ) Date of Birth

शब्दों में /In words…………………………………………………………………………………………………………………………….................….

3. Age as on 31.3 .2021 Years Months Days

4. Blood Group of the child

5. क्या आप सामान्द्य श्रेणी /अनुसूथिि जाति /जनजाति / ओ बी सी से / आथर्थषक रूप से कमजोर िर्ष /बी पी एल/ विकलांर्/इकलौिी कन्द्या यदद हां िो प्रमाण -पत्र संलग्न करें ।
Do you belong to Gen./SC/ST/OBC/EWS/BPL/Disabled/S.G. Child ? Yes No If yes, attach relevant certificate ……….
6. तनम्नललखिि में से जो लार्ू हो उसे सही (√)करें
सामान्द्य श्रे णी अन0ु जाति अन0ु जन जाति ओ.िी.सी. आथर्थषक रूप से कमजोर िर्ष बी पी एल विकलांर् इकलीैिी कन्द्या
Gen. Cat SC ST OBC EWS BPL Disabled SG Child

-
7 मािा-वपिा का ब्यौरा/ Details of Mother/ Father मािा Mother वपिा Father

(i) नाम/ Name (in Capital letters)……………….......................................................................................................................................

(ii) राश्रीयिा/ Nationality ……………………………………………………………………………………………………….……………………..…
(iii) व्यिसाय/ Occupation …………………………………………………………………………………………………………………………………
(iv) कायाषलय का नाम, परू ा पिा ि दरू भार् ् …………………………………………………………………………………………………………………………………
Name of Office and full address ………………………………………………………………………………………………………………..……….………
with telephone numbers ……………………………………………………………………………………………………………………………….…
(v) पण
ू ष आिासीय पिा ि दरू भार्
Full residential address with …………………………………………………………………………………………………………………………………….…
telephone numbers(with proof) …………………………………………………………………………………………………………………………………….…
(vi) विद्यालय से दरू ी/ Distance from KV* ………..……………………………………………………………………………………………………………...
(vii) स्र्थाई पिा/Permanent Address …………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………….
(viii) मूल िेिन/ Basic Pay ………………………………………………………………………………………….……………………………...
(ix) 31/3/2020. िक सेिाकाल के दौरान 7 िर्ों में र्थानान्द्िरणों की संख्या
No.of transfers during 7 years as on 31-3-2020 of the year………………………………………………………………..……………

(x) श्रेणी रक्षा/ केन्द्रीय कमी/ स्िायिशासी ि अन्द्य Category to which the Parent belong to Defence/Central Govt./ Autonomous body & others -
-------------------------------------------------------------------------------------------------------------------

मैं एिद् द्िारा यह प्रमाखणि करिा हूूँ कक उपयुक्

ष ि प्रविष्टियां मेरी जानकारी में सत्य हैं। I certify that the above entries are true to the best of my knowledge.

Signature of Parent

Date:………………… Name…………………...

Acknowledgement
S. No Registration No……

Received an application from Shri/Smt……………………………………………………………………………………….for registration of her/ his son/

daughter…………………………………………………………for admission to class………………………..

Date…………………… Kendriya Vidyalaya (Stamp)

 -2-
lsok izek.k&i= /SERVICE CERTIFICATE
Central Govt/ State Govt

izekf.kr fd;k tkrk gS fd Jh@Jherh--------------------------------------------------------------------------dk;kZy;@ea=ky; ----------------------------------------------------------- esa dk;Zjr gSaA os j{kk

lsok@dsUnzh; fjtoZ iqfyl cy@lhek lqj{kk cy@,u-,l-th-@,l-ih-th-@lh-vkbZ-,l-,Q-@ dsUnzh; ljdkj स्िायत्त laLFkk@lkoZtfud {ks= ds miØe

ds@dh deZpkjh gSa ftudk iw.kZ foÙk izca/k dsUnzh; LFkkukarj.kh; @ राज्य ljdkj स्िायत्त laLFkk@lkoZtfud {ks= ds miØe ds@dh तनयलमि deZpkjh
gSa ftudk iw.kZ foÙk izca/k LFkkukarj.kh; gSaA

;g Hkh izekf.kr fd;k tkrk gS fd Jh@Jherh--------------------------------------------------------------------------------------tks---------------------------------------------------------------------------ds

ekrk&firk gSa] muds 31-03-2020 से पहले साि िर्ष के दौरान --------------------------LFkkukarj.k gq, gSaA ,dd@dk;kZy; vkSj ,slh rSukfr;ksa dh vof/k dk C;kSjk uhps
fn;k x;k gS] ftlds dkj.k LFkku cnyuk iM+rk gSA

Certified that Shri/Smt……………………………………….………………….……………….is working in the office/Ministry of

…………………………………………..….... He/She is an regular employee of Defence Service /CRPF /BSF /NSG /SPG /CISF /Central
Govt. /Autonomous Body/Public Sector Undertaking fully financed/partially financed by Central Govt. / State Govt. /
Autonomous Body/Public Sector Undertaking fully financed/partially financed by State Govt. and his/her services are
transferable.
It is further certified that Shri/Smt …………………..………………………………………………. Father / mother of
……………………………….………………… has/had……………(No. of posting) transfers during the preceding last seven years from
31st march 2020. The Unit Office & the duration of such postings involving change of station are given below:-
Ø-la- inuke LFkku Bgjus dh vof/k Period of stay vkns'k la[;k

S.No. Designation Place of ls From rd To Order No.

Posting

1.

2.

3.

4.

5.

6.

7.

LFkku ,oa fnukad dk;kZy; v/;{k dk uke] in vkSj gLrk{kj ¼dk;kZy; dh eqnkz ad lfgr½

Station with date Sign. & Name in block letters and design. of the head of office with
stamp nwjHkk"k % Telephone No……………………………….

fVIi.kh % j{kk laLFkkukasa esa dke djus okys deZpkfj;kaas ds ekeys esa lsok izek.k i= ij deku vf/kdkjh ds gLrk{kj visf{kr gSA
Note : The service Certificate should be signed by the officer commanding in case of employees working in defence establishment.
 SINGLE GIRL CHILD

Rs. 100/- Stamp paper ( Notary) Affidavit

I……………………………………………….aged…………………………..years, Indian
Inhabitant occupation …………………..…………………………………….Resident of
..………………………………………………………………………..… is mother/father of
………………….………………….. Date of Birth…………………………….... Submitting
my undertaking to the Head of the Institution in Class I Vide KVS Admission Guidelines
2021)

1) I hereby declare that Miss………………………………………......…. is the only girl

child in my family ( with no male/female sibling). I understand that it shall be my
sole responsibility to inform you about any change in status of single girl child in
the family immediately, if and when it occurs.

2) I am also aware that in case it is detected at any time that the affidavit sworn by
me is false, appropriate action will be taken by the school authorities and KVS
against me.

Signature of father Signature of mother

Residential address with

Contact number:

Solemnly affirmed at ………………..

This………..day of………..20……….

BEFORE ME
Explained and Identified by me,

Advocate