THE ASSEMBLY OF GOD CHURCH SCHOOL CHAKRATRITHA ROAD, PURI 752 002 APPLICATION FORM FOR NURSERY TO STD V

Please Indicate by circling the class admission is being sought for Nursery I II III IV V Photo to be affixed here (Write the name behind photograh)

(Original Application Form is to be filled by Hand, in block letters and submitted. Submisson of photocopied form will be rejected) 1. CATEGORY______________________________ 2. CANDIDATE’S: a. Name:____________________________________________________________ b. Date of Birth:_______________________________________________________ (as per Muncipal Birth Certificate/Baptism Certificate) c. Religion:___________________________________________________________ d. Nationality:_________________________________________________________ e. Mother tongue:______________________________________________________ f. Current School:______________________________________________________ 3. MOTHER’S DETAILS a. Name:_____________________________________________________________

b. Religion: ___________________________________________________________ c. Nationality: _________________________________________________________ d. Educational Qualification:______________________________________________ e. School/College:______________________________________________________ ______________________________________________________ f. Occupation: _________________________________________________________ g. Monthly Income: _____________________________________________________ h. Office Details: _______________________________________________________ Office Name:________________________________________________________ Adress:_____________________________________________________________ _____________________________________________________________

(PTO)