ANNUAL MIDDLE STANDARD EXAMINATION 2000 (For Private Candidate only) Category: Model/Non-model (Tick the category as applicable) Particulars to be filled in by the candidate neatly and legibly in his/her own handwriting 1. Name of the candidate (Block letters) : ____________________________________________ 2. Sex (boy or girl) : ____________________________________________ 3. i) Father's name ( block letters) : ____________________________________________ ii) Mother's name (block letters) : ____________________________________________ 4. Whether belonging to Scheduled Castes or Tribes. If so, state Caste or class or Tribe : ____________________________________________ 5. Date of birth (a) In figures : ____________________________________________ (b) In words : ____________________________________________ 6. Subject and Medium of Examination (strike off which is not applicable) Subject Medium (a) English (b) Mathematics (c ) General Science (d) Social Studies (e) Ist Language _______________Hindi-I/Punjabi-I 2nd Language _______________Hindi-II/Punjabi-II Roll No.________ (to be assigned by office) Space for affixing photo (For both male and female candidate) (g) Drawing/Sanskrit/Domestic Science/Music (write down in which subject students has to appear) 7. Have you ever been disqualified by the Chandigarh Education Department or any other Board or examining body in any Examination on _______________? If so, give name of the body by which disqualified ___________________________________________ period for which disqualified ____________________________ Roll No.____________ _________________ Year_________ 8. i)Amount of Examination Fee remitted Rs______________________________________ ii) No. and date of Treasury Challan,-vide which the fee has been deposited ___________________________________________________________ 9. Residential address _______________________________________________________ Telephone No. _______________________ 10. Have you studied privately throughout?_______________________. If not, has your name been on the tools of any recognized school during any part of the 9 months preceding the examination ? _________________________________________________________________ 11. Are you appearing in the Examination for the 1st time? _____________________________ If not, the year and No under which you appeared before _______________ year _____________ Roll No. ____________________. 12. Have you passed the 5th class (primary examination)? _____________________________ If so, in which year and from where ____________________________ Name of Institution _________________________________________________________________. I solemnly declare that the statement made by me in this form is correct and true and nothing has been concealed and that I will render myself liable for disqualification if the above statement is found to be incorrect at any stage. Signature of Father/Guardian Signature of candidate CERTIFIED TO BE RECORDED BY THE AUTHORITY ATTESTING THE FORM (i) Certified that the candidate is of good conduct. (ii) Certified that the candidate has not been debarred by the Department from appearing in the examination. (iii) Certified that the candidate has studied privately throughout or has not been on the rolls of any recogonised school for a period of nine months preceding the examination. (iv) Certified that the candidate has signed the Admission form in my presence. Name (in block letters) and Signature of seal of the Address of the Attesting Officer Attesting authority. REMARKS REGARDING ELIGIBILITY BY THE OFFICE Eligible/Ineligible Assistant _______________________________ Supdt........ Reasons, if not eligible ________________________________________________________ ___________________________________________________________________________ Incompletion noted ___________________________________________________________ AUTHORITIES COMPETENT TO ATTEST THE FORM: (i) The Director of Public Instructions, Chandigarh Administration. (ii) The Principals of Government and affiliated Colleges at Chandigarh. (iii) The Directors, Regional Institute of English/State Institute of Education, Chandigarh. (iv) The Principal/Headmaster/Headmistress of Government or Privately Managed Schools recogonised up to Middle or High/Senior Secondary Standard Level under the Chandigarh Administration. (v) Deputy Director, Adult Education, Chandigarh Administration. (vi) The Assistant Director, Vocational Education/Adult Education, Chandigarh Administration. (vii) The District Education Officer, Chandigarh Administration. (viii) The Deputy District Education Officer, U.T. Chandigarh. (ix) Sr. Lecturer, State Institute of Education, Sector-32, Chandigarh. Note: The Manager/Presidents of recogonised Schools and Head of Schools recogonised up to Primary Standard are NOT competent to attest the form. Such form attested by them will not be entertained. RATES OF ADMISSION FEE: (a) Full Subjects Rs.100/- (b) Additional Fee for subjects involving Practical Examination i.e Music/Domestic Science. Rs.5/-per subject LATE FEE: Late fee will charged as notified by the Education Department, Chandigarh Administration. Failed candidates belongings to Scheduled Castes/Tribes/Backward Class are not exempted from the payment of the examination fee and they will have to deposit at the above mentioned rates. Roll No._________ ROLL NO. FORM (to be assigned by the office) (The candidate will be admitted to the Examination Centre only on production and Delivery of this Roll. No. Slip) Admit...............Son/Daughter of Shri......... To the Middle Standard Examination to be held in February,200..... on the date As in the Date-Sheet at the under-mentioned Centre. Centre of Examination ................. Centre No....... Signature of the Candidate ........................ (The candidate must sign here before submitting form to the Department) Registrar Examination Education Department, Chandigarh Administration To be filled in by the candidate (in block letters) M.S Examination, 200____________ M.S. Examination 200___ ____________________________ ______________________ ______________________________ ______________________ ______________________________ _______________________ [Note- Candidate's Home Address only is to given] 1. The Examination fee in cash up to Rs. 100 should be deposited in the office and above Rs. 100/- should be deposited in the Central Treasury under the head 0202-Education-Sports-Arts and Culture-01-General Education-800-Other Receipts-Examination Fee 200.... One copy of latest photo duly signed and attested by the same authority should be pasted here. Name and address at which Roll. No should be sent Name and full address at which Certificates or Result Card should be sent 2. Admission form and fee sent through Heads of Private Institutions will not be accepted and the fee shall not be accounted for towards the candidate's accounts. 3. If a candidate pays his examination fee only but does not submit his form, the fee shall not be refunded. 4. Roll numbers to the candidates shall be sent to the candidate Under Certificate of Posting. 5. Duplicate Roll. No will be issued only after a fee of Rs. 15/- has been deposited. 6. No Roll No. shall be issued to a candidate if he/she sends incomplete form or does not remit full fee for the examination. Responsibility for the incomplete form shall not rest with the department. 7. If it is discovered at any stage that the candidate has made a wrong statement, he will be responsible for consequences involving cancellation of his candidature and disciplinary action and the decision of the department will be final and binding on the candidate. 8. (a) An amanuensis is permissible only in the case of blind candidates or candidates permanently disabled from writing on the payment of extra fee for additional supervisor and the remuneration payable to amanuensis. Such candidate must submit application on ordinary paper with proper medical certificate for amanuensis along with their admission form. An amanuensis may be allowed by the department on request on payment of fee in case of candidate is in capacitated temporarily during examination and a proper medical certificate is produced. 8 (b) Deaf or blind candidate should produce a certificate of deafness or blindness from the Head of the Department of Ear, Nose and Throat of a Government Hospital at Chandigarh. 9. Refund of admission fee shall not ordinarily be permissible. However, such a fee may be refunded with special sanction of the Registrar if a candidate is declared ineligible to appear in the Examination and request for refund of fee together with Roll. No. Slips are received back at least 5 days before the commencement of the relevant examination. 10. Attested copy of the date of birth proof i.e. birth certificate issued from Registrar Birth and Death or Government competent authority or S.L.C (from Govt/Recogonised School duly countersigned by the concerned DEO)
