Site Name

1.	Name of the Candidate *	* *
2.	Name of the Father *	* *
3.	Name of the Mother *	* *
4.	Gender *	Male Female *	5.	Date of Birth *	* * *
6.	Area in which candidate Resides *	-Select- 1-Rural 2-Urban	7.	Religious
	Caste Category *	*		Disability Status of the Candidate *

A.	At *	*	B.	PO *	*
C.	District *	*	D.	Block *
E.	PIN *	* *

A.	School District *		B.	School Block *
C.	School Name *
D.	School Address *
E.	Pin	*

	Type of Institution/School in which studying at Class level *	*		Area in which School is Located *	-Select- 1-Rural 2-Urban *
	At National Level  * (a) Medium of Examination		(b).	Language Subject

	Father's Education *	*		Father's Occupation *	*
	Mother's Education *	*		Mother's Occupation *	*
	No. of family members living in the house *		*
	No. of Brothers *	*		No. of Sisters *	*
22.	Percentage of Mark Secured at Class IX Annual Exam  *			(if mark in cgpa convert to percentage) *
	At what number is the candidate among his/her brothers and sisters *			*
	Parental Annual Income (Proof to be attached) *

A.	Telephone	* *	B.	Mobile No	*
C.	E-Mail ID	(If you do not have email id, provide school's/HM's email address) InValid

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