ODISHA ADASRSHA VIDYALAYA, BADAPUR, PATRAPUR

(AFFILIATED TO C.B.S.E., NEW DELHI)

APPLICATION FORM FOR ADMISSION: CLASS XI
(SCIENCE) SESSION: 2021-22
STUDENT DETAILS:
Name of the Student:
(In block letters)

Date of Birth: Age: Years Months

(As on 1st April 2021)

Gender: Mother Tongue: Nationality:

Religion: Caste: (SC / ST / GEN / OBC / PH)

Sub-Caste: Blood Group:

Aadhaar No: Bank a/c No:

Ifsc Code:________________________Branch Name:___________________________
Permanent Address: Residential Address:

Contact Numbers: 1. 2.

Class and stream in which admission is sought: XI(Science)

Distance from School (in km):

Subjects Combination Available: 1. English Core (301) 2. Mathematics (041)

3. Physics (042) 4. Chemistry (043) 5. Biology (044)

Subjects Opted: 1. 2. 3.
4. 5.
ACADEMIC DETAILS:
Name and place of the school last studied:

Percentage of marks secured in class X:

Marks and Grade obtained in:

a)Mathematics:__________/___ b)Science_________/_______ c)English__________/_____

Roll No of class X: Year of passing:_____________

Name of the Board: (CBSE / ICSE / BSE)

FAMILY DETAILS: (Father/Mother/Guardian)
Father’s Name:

Educational Qualifications: Occupation:

Mobile No: E Mail:

Mother’s Name:

Educational Qualifications: Occupation:

Mobile No: E Mail:

Guardian’s Name:

Educational Qualifications: Occupation:

Mobile No: E Mail:

Documents to be attached along with application form-

i) Board Mark sheet Xerox(Signature of Principal/H.M)
ii) Aadhaar card Xerox
iii) Resident Certificate Xerox

DECLARATION
I do hereby declare that the above information provided by me is complete and correct to the best of my
knowledge and belief. I understand that rendering incorrect information shall disqualify the applicant for
admission to the school. I have carefully read the rules and regulations laid by the school and being
desirous of having my ward educated in ODISHA ADARSHA VIDYALAYA under Patrapur block. I hereby
agree to abide by them in all respects. I undertake that I shall not indulge in any unwanted activities in order
to maintain the sanctity of the teacher - taught relationship, if get admitted.

Signature of the student with date Signature of the parent with date

FOR OFFICE USE

ONLY
Application received on: Acknowledgement No:

Admission No and Date: Student ID Card No:

Section Allotted:____(XI A / XI B) House Allotted:

Subject Combination Allotted: 1. English 2. Mathematics

Core (301) (041)
3. Physics 4. Chemistry 5. Biology
(042) (043) (044)
Special Remarks(if) ____________
any):
Admission Committee
1.________________
2.________________
3.________________