jk"Vªh; eqDr fo|ky;h f'k{kk laLFkku

NATIONAL INSTITUTE OF OPEN SCHOOLING QkeZ la[;k

A-24/25, Institutional Area, Sector-62, NOIDA, U.P. Form No..................................
izos'k ds fy, vkosnu i= 2010-11 / Application Form for Admission 2010-11
lanHkZ la[;k
¼tks izR;kf;r laLFkk ¼,vkbZ½ }kjk vkWu&ykbZu iathdj.k ds ckn fn;k tk,xk½
Reference Number
(to be given by the Accredited Institution after the On-line registeration)

MPORTANT INSTRUCTIONS
1. Please fill the Form ONLYAFTER reading the instructions given at Appendix ‘J’. / d`i;k ifjf'k"V ^ts* ij fn, x, funsZ'kksa dks i<+us ds ckn gh QkWeZ HkjsaA
2. Follow these steps: (i) Fill the form but do not sign it yet; (ii) Paste your photograph; (iii) Then sign form and submit of them to the AI (Study Centre). /
bu ckrksa dk ikyu djsa (i) QkWeZ Hkjsa fdUrq vHkh gLrk{kj ugha djsa, (ii) ewy izfr ij QksVks fpidk,¡ (iii) QkWeZ ij gLrk{kj djsa vkSj ,vkbZ v/;;u dsUnz ij tek djsaA
3. Use Blue/Black Ball Point Pen Only for filling up the form/QkWeZ Hkjus ds fy, dsoy uhyk@dkyk cky isu dk iz;ksx djsaA

1. fo|kFkhZ dk iwjk uke @Name of Candidate in CAPITAL Letters

2. firk dk iwjk uke @Father’s Name in CAPITAL Letters

3. ekrk dk iwjk uke @Mother’s Name in CAPITAL Letters

4. vfHkHkkod@laLFkk dk iwjk uke @Guardian's/Institution's Name in CAPITAL Letters for Orphan

5. i=&O;ogkj@vukFkky; ds fy, irk @Postal Address in CAPITAL Letters/Orphan Homes

Address

ftyk@District
jkT;@State fiu dksM Pin Code
E-mail

;gk¡ ls eksM+sa@FOLD FROM HERE

6. tUefrfFk@Date of Birth nwjHkk"k@ Telephone

7. fyax @Gender 13. ekr`Hkk"kk 19. jgus dk LFkku ;gk¡ viuk 4 X 3 lseh
Mother Tongue Place of Residence vkdkj dk QksVks fpidk,¡A
8. oxZ @ Category fiu vFkok LVsiyj dk
14. jk"Vªh;rk @Nationality 20. vkidk HkkSxksfyd {ks= iz;ksx u djsaA
9. fodykaxrk @ Disability 15. /keZ@Religion Your Geographical Area PASTE HERE
PHOTOGRAPH OF
THE STUDENT OF
10. oafpr oxZ@Disadvantaged 16. vkidh iwoZ ;ksX;rk@Your 21a. jkstxkj@Employment 4 x 3cm
Group Previous Qualification IN THIS BOX ONLY
21b. vU; ikB~; lgxkeh fØ;k,a DO NOT USE PIN OR
10a. vukFk@Orphan Extra curricular activities STAPLER.
17. firk dh 'kSf{kd ;ksX;rk
11. ikB~;Øe ftlds fy, vkosnu Father's Edu. 22. ifjokj dh okf"kZd vk;
fd;k gS@Course Applied Qualification Annual family income
for
18. ekrk dh 'kSf{kd ;ksX;rk 22a.vkfFkZd :i ls fiNM+h
12. vè;;u dk ek/;e@Medium Mother's Edu. Js.kh@Economically fo|kFkhZ ds gLrk{kj
of Study Signature of the Student
Qualification Backward Class

23. fo"k;ksa dk pquko ¼U;wure 5 rFkk vf/kdre 7] rkfydk&1 ns[ksa½@Choose Subjects (Minimum 5 and Maximum 7, See table-1)

24. ek/;fed ijh{kk / Xth Board Exam

(d) mÙkh.kZ gksus dk o"kZ /(a)Year of Passing ¼[k½ vuqØekad la-/(b) Roll No.
¼x½ cksMZ dk dksM@(c) Code of the Board ifjf'k"V ^ts* ij fn, x, funsZ'k ds vuqlkj dksM fy[ksaA@Write the code as per
instruction mentioned at Appendix-J.

25. dqy ns; 'kqYd dh jkf'k@Total amount of fee paid

(a) izos'k 'kqYd + vfrfjDr fo"k; 'kqYd + Vhvkslh 'kqYd = dqy 'kqYd
Admission Fee Additional Subject Fee TOC Fee Total Fee
(b) cSad Mªk¶V la-@Bank Draft No. (c) cSad Mªk¶V dh frfFk@Date of Bank Draft
(d) cSad Mªk¶V tkjh djus okys cSad dk uke o LFkku@Name of the Bank & Place of issuing Bank Draft _____________________________________
(e) Unique number of Syndicate/Indian Bank
(If fees paid through Challan)
26. D;k vki ØsfMV LFkkukUrj.k (TOC) ds fy, vkosnu dj jgs gSa / Whether you are applying for Transfer of Credit
27. ek= jk"Vªh; eqDr fo|ky;h f'k{kk laLFkku / lhch,lbZ@lhvkbZ,llhbZ@jkT; eqDr fo|ky;@Hkkx 2-6 esa fn, x, jkT; f'k{kk cksMZ ds iwoZ fo|kfFkZ;ksa ds fy,
For Ex-Students of NIOS /CBSE /CISCE /State Open School/State Board of Education as per section 2.6 only
¼d½ ukekadu la[;k ¼[k½ ijh{kk dk o"kZ
(a) Enrolment No. (b) Year of Exam.

¼x½ Vhvkslh cksMZ dk dksM@(c) Code of the TOC Board Write the code as per instructions mentioned at Appendix-J and
section 2.5 & 2.6.
28. mÙkh.kZ fd, x, fo"k;ksa dk fooj.k ftuds ØsfMV LFkkukarj.k pkgrs gSa @Details of Subjects passed for which transfer of credit is opted
Ø- la-
fo"k;@Subjects(s)
,uvkbZvks,l dk fo"k; dksM izkIrkad@Marks Obtained
S.No. Subject Code of NIOS fl)kar@Theory iz;ksx@Practical dqy@Total
1.
2.
3.
4.

29. D;k vki Lo&izek.k i= ds vk/kkj ij ,uvkbZvks,l ds ekè;fed ikB~;Øe esa izos'k ysuk pkgrs gSa\ ;fn gk¡ rks Lo&izek.k i= ij gLrk{kj
djsaA@Whether you wish to get admission in Secondary Course of NIOS on the basis of Self Certificate. If yes, please sign the Self Certificate.
Lo&izek.ki= ¼mu lHkh ds }kjk gLrk{kj fd;k tk,xk tks fo|ky; NksM+us dk izek.ki= layXu ugha dj jgs gSa½
SELF CERTIFICATE (to be filled by all those not enclosing School Leaving Certificate)
eS lR;kfir djrk g¡w fd eSa ek/;fed Lrj ds ikB~;Øe i<+us esa leFkZ gw¡
Certified that I have studied enough to be able to pursue Secondary level course.
fo|kFkhZ ds gLrk{kj@Signature of the Candidate
vkosnd dh ?kks"k.kk ¼lHkh vkosndksa }kjk Hkjk tk,xk½ / DECLARATION BY APPLICANT (TO BE FILLED BY ALL APPLICANT)
I hereby declare that I have read and understood the conditions of eligibility and I fulfill the criteria for the course for which I seek admission. I have furnished all the
necessary documents and information correctly. I have filled this form in my own handwriting. I understand that my candidature is liable to be cancelled by NIOS in the
event of any information or document is to be found misleading or incorrect at any stage. I accept the rules as laid down in the Prospectus. eSa ?kks"k.kk djrk g¡w fd eSaus os lHkh
;ksX;rk 'krsZa i<+dj le> yh gSa ftl ikB~;Øe ds fy, eSa vkosnu dj jgk g¡wA eaSus lkjh t#jh lwpuk,a vkSj nLrkost lgh&lgh fn, gSaA eSaus [kqn vkosnu i= Hkjk gSA eSa tkurk gw¡ fd ;fn ;s
lwPkuk,¡ xyr ;k Hkzze esa Mkyus okyh gksrh gSa rks jk"Vªh; eqDr fo|ky;h f'k{kk laLFkku }kjk esjh mEehnokjh lekIr dh tk ldrh gSA eSa foojf.kdk esa fn, x, lHkh fu;eksa dk ikyu d:¡xkA
frfFk @Date...............
ekrk&firk@vfHkHkkod ds izfrgLrk{kj@Countersignature of Parent/Guardian ______________________________ fo|kFkhZ ds gLrk{kj@Signature of Candidate
LFkkbZ irk@Permanent Address ___________________________________________________________________________________________________________________________
Bank details for Dr. Ambedkar National Scholarhsip (applicable for SC and ST only). For details please see section 4.11 ______________________________________
cSad dk uke@Bank Name : ________________________________________________ cSad dk irk@Bank Address : ________________________________________
__________________________________________________________________________________ fiu @Pin__________________________________________________________

leUo;d dk izek.k i=@Certificate From Coordinator

mijksDr rF;ksa dks ,uvkbZvks,l@lh-ch-,l-bZ-@lh-vkbZ-,l-lh-bZ-@lacaf/kr jkT; cksMZ@jkT; eqDr fo|ky; }kjk tkjh ewy vadlwph@izek.ki= ls lR;kfir dj fy;k x;k gSA
Above Statements have been verified with the original Marksheet/Certificate issued by NIOS/CBSE/CISCE/concerned State Board/SOS.
layXudksa dh tkaPk dhft,] lgh dk fu'kku ¼3½ yxk,¡@CHECK THE ENCLOSURES, Please Tick (3)

1. ewy izos'k&i= 7. 'kSf{kd ;ksX;rk lca/kh Lo&izek.ki=

Original Admission Form Self Certificate regarding educational qualifications
2. izos'k i= dh nks izfr;k¡ nLrkostksa ds lkFk 8. nloha ijh{kk mÙkh.kZ djus dh vad rkfydk dh izfr
Two photocopies of Admission Form alongwith enclosures Photocopy of Marksheet of Class X Board Examination
3. tUe frfFk izek.ki= 9. HkwriwoZ lSfudksa ds fy, fu;ksDrk ls izek.k i=
Certificate of Date of Birth Certificate from the Employer for Ex-Servicemen
4. vuqlwfpr tkfr@vuqlwfpr tutkfr izek.ki= 10. fodykax O;fDr ds fy, ljdkjh vLirky ls izek.k i=
Certificate for SC/ST Certificate from a Government Hospital for a handicapped person
5. fiNys fo|ky; dk LFkkukarj.k izek.ki= 11. Vh vks lh ds fy, d{kk nloha ;k ckjgoha cksMZ Qsy@dEikVZesaV dh ewy vad rkfydk vkSj
Transfer Certificate from the last school attended ysfeusV dh x;h vad rkfydk Lohdkj ugha dh tk;sxh
6. fuokl LFkku ds irs dk izek.k&i= Original failure/compartment Marksheet of class X or XII for TOC
Proof of Residence and Laminated Marksheet is not acceptable

izekf.kr fd;k tkrk gS fd mi;qZDr layXudksa lfgr 'kqYd ds lkFk vkosnu i= lh/ks fo|kFkhZ ls izkIr gqvk gSA@It is certified that Application Form with fee is
received directly from the learner alongwith the above mentioned enclosures.

'kqYd dk fooj.k @ FEE STRUCTURE

lkekU; oxZ NwV izkIr oxZ leUo;d ds eqgj lfgr gLrk{kj
General Category Exempted Category Signature with seal of Co-ordinator
ikB~;Øe vuq tkfr@vuq tutkfr@ iwjk uke@Full Name ____________
Course iq#"k efgyk HkwriwoZ lSfud@fodykax
Male Female SC/ST/Ex-Servicemen/
Handicapped

ek/;fed ikB~;Øe
Secondary Course
(i) ikap fo"k;ksa ds fy, For 5 subjects 1000 750 550
(ii) ,d vfrfjDr fo"k; ds fy, For an additional subject 150 150 150 ikB~;Øe dk Lrj
izR;sd fo"k; ds fy, Vhvkslh ds

Course level ikB~;Øe 'kqYd

Course fee for each subject
fy, 'kqYd

Fee for TOC

mPprj ek/;fed ikB~;Øe
Senior Secondary Course ek/;fed Lrj
250 150
(i) ikap fo"k;ksa ds fy, For 5 subjects 1150 900 625 mPprj ek/;fed Lrj
250 180
(ii) ,d vfrfjDr fo"k; ds fy, For an additional subject 180 180 180