PERSONAL INFORMATION FORM

(To be filled in by the Parent/Guardian of the Candidate with the help of the
Headmaster/Headmistress of the School from wherethe candidate passed
Class VExamination)

1. Name of the Candidate:

Aadhar Number: PHOTO

of student
2. Sex Male Female TG

3. (a) Category
Gen OBC SC ST

(b) Caste
4. Date of Birth
Date Month Year

Date of Birth in Words

5. Fathers Name
6. Mother's Name
7. Name of the Guardian and
relationship with him/her, if applicable:
School(s) from where the candidate passed Class III, IV and V.
CLASSES
Particulars
IV

(A 0Month &Year of Joining

(ii) Month &Year of Passing
(B) () Name of the School
(1) Is Itarecognized schoo1? (YES/NO)
(CY Name of the Village or Town in which
school is located.

D) Name of the Block

(EJ Name of the District
(FT Location of the SchoolIndicate
RURAL/URBAN

(Separate certificate is to be obtained if the candidate had studied classes IIl, IV &Vin
different schools)
 CERTIFICATE

CONCERNED)
(BY PARENT/GUARDIAN OF THE CANDIDATE
knowledge and
Certified that the information given above is true to the best of my
found incorrect, the
belief. In case, any part of information furnished by me is
selection/study in
admission of my child/ward may be cancelled at any stage of
Competent
JNV. I am ready to produce the relevant certificates issued by
Authorities as and when asked for.,

Signature of PARENT/GUARDIAN

Entries verified, certified and found correct.

Signature of the HEADMASTER/HEADMISTRESS

Name:

School Seal
Designation:

(NOTE FOR THE HEAD OF THE SCHOOL: -Following Certificate is required to be

issued in respect of candidate selected for admission in JNV in the respective
district).

CERTIFICATE BY THE HEAD OF THE SCHOOL

Certified that the information given in pages 1 & 2 is found correct as

school records.
per our
It is also certified that Master/Kumari
was admitted in this School in Class on
(date) and passed Class on
(date).

Signature of the Head of Institution

last studied with School Seal
Date:
 UNDERTAKING BY THE PARENTI GUARDIAN

Certified that the information given in the application form for admission into Class
VI inJawahar Navodaya Vidyalaya, District: for the academic year
2025-26 for imy ward is true to the best of my knowledge and belief. In case any part
of the information furnished by me is found incorrect, admission of my ward may be
cancelled at any time. Iam ready to produce relevant certificates issued by the
competent authority to your office when asked in support ofentries in my original
application.

Signature of the Parent/Guardian

Address of parent/guardian:
Name
Street
Village.
Mandal/Block
Pin Code:

STD Code:_Phone NO
Mobile No:

To-oS

UNDERTAKING *

(Father/Mother/Guardian) of Kumari/Master
who got selected for admission into Class VI in Jawahar Navodaya Vidyalaya,
...District hereby give an undertaking that I am ready to pay Navodaya Vikas
Nidhi from Class-IX to XII every month as per norms of Navodaya Vidyalaya Samiti.

Signature of the parent/Guardian

* Note: This is not applicable to SC/ST/ Divyang students, all girl students and the wards of
parents whose Income is below poverty line (BPL).
 UNDERTAKING FOR MIGRATION
(TO BE FILLED BY PARENT IN PRESENCE OF PRINCIPAL, JNV)

(Father/Mother/Guardian) of Kumari / Master

who got selected for admission in Class VI in JNV,

District hereby give an undertaking that I understand that, for promotion

of National Integration and as per the scheme at JNVs, 30% of the students of class IX
from one JNV have to migrate to another JNV from non-Hindi speaking area to Hindi
speaking area and vice-versa and I agree to abide by the rules of NVS in this regard.

Signature of the parent/guardian

Full Name:

Address:

Mobile No:

Land line with STD COde:

 MEDICAL FITNESS CERTIFICATE

JAWAHAR NAVODAYA VIDYALAYA

DISTRICT:

01. Name of [Link]

02. Father's Name

03. Address

04. Date of birth

05. Height
06. Weight
07. Abdomen
08. Chest

09. Vision LEFT RIGHT

10 Ears

11. Throat

12. Locomotor System

13. State of vaccination
14. Skin

15 Blood Group

16 Dental Hygiene
17. Remarks of Medical Officer Recommended/not recommended for
admission/Recommended to C.M.0 for
Verification if any.

PHOTO OF THE
STUDENT

CIVIL SURGEON
 MEDICAL ANTECEDENTS

UNDERTAKING

We, Shri. (father) &Smt. (mother),

the parents of Master/Miss do hereby declare :

that our ward doesn't suffer from any of the medical ailments listed below.

1. Head Injuries
2. Puo- Intermittent
3. CHD- Congenital Heart Disease
4. AA - Acute appendicitis
S. Epilepsy - Convulsions (Injury, Fever)
6. Blood Disorders (Sickle cell Anemia, Haemophillia)
7. Communicable Diseases (TB, Hepatitis A&B)
8. Skin Disease.

We further declare that our ward Master/Miss_ doesn't have any previous
medical history which required/still requires prolonged or intermittent periods of medical
confinement either in a hospital/nursinghome or in our house.
Certified that the information furnished above is true to the best of our knowledge. Any willful
suppression or false information on the medical antecedents revealed later, would make the
admission of our ward invalid and liable for actions as deemed fit by the Vidyalaya and
Navodaya Vidyalaya Samiti.

PLACE: FATHER'S SIGNATURE

DATE: NAME:

MOTHER'S SIGNATURE:

NAME:

ADDRESS:
 DISABILITY CERTIFICATE
If the candidate is selected under disabled quota he/she should bring the certificate
issued by the competent authority.

CATEGORYICOMMUNITY CERTIFICATE (SCIST)

Category certificate in the prescribed format from the competent authority is to be

submittedby the candidate, wherever necessary.

CATEGORYICOMMUNITY CERTIFICATE (OBC)

O8C certificate is to be submitted only as per Central List.

DATE OF BIRTH CERTIFICATE

The copy of Birth Certificate issued by Government Authority concerned is tobe

submitted by the provisionally selectedcandidate.
e-|3

RURAL AREA CERTIFICATE

(To be issued by the Revenue Officer of concerned Block)
This is to certify that Master/Kumari Son/Daughter of
Shri studied classes III,IV &V in L(Name of the
school)of block. and the school is located in the village which
belongs to rural area of District; State:

(Signature of the Revenue Oficer)

Block:
District.
Office Seal:

Dated:
 RESIDENCE CERTIFICATE

the time
(To be furnished by the parents of the qualified children at
of admission to JNVs)

Asper Jawahar Navodaya Vidyalaya, District State

dated: my ward Master/ Kumari
letter No:.
has qualified the entrance exam for admission to
Class VI at JNV, District ,State for the session

Iam residing alongwith my ward mentioned above at the following address:

Village:
Town:
District:
State:
Pin Code:

It is certified that the information furnished by me is true and no fact has

been Concealed.

Signature of the parent.

Full name:
Address:

Copy ofa certificate to prove the residence in the district like Aadhar Card of the same district,
Residence Certificate issued by the competent authority is to be attached

CERTIFICATE

(TO BE FILLED UP BY THE DISTRICT AUTHORITIES AND ISSUED UNDER THE SIGNATURE OF
TEHSILDARTO THE PARENTS OF THE CHILD SELECTED FOR ADMISSION TO CLASS VI IN
JNVS THROUGH JNVST)

This is to certify that the above information furnished by Shri/Smt

Father/Mother of Master/Kumari acandidate
for admission to class VI in JNV, District_ has been verified from the records
and is found to be correct.

The area where residence is located falls under (Rural/Urban) area of the district_

Signature of Tehsildar
(With Seal)
 SEHOOINFORAVMATION SYSTEA-DATA

BAGHPAT
NAVODAYA VIDYALAYA, SHARFABAD,
PM SHRI JAWAHAR
PEN N0:
1. ALPHACODE
RESERVE STAFF WARD
2. SELECTION CATETGORY OPEN

[Link] NAME

4. DATE OF BIRTH :- DD MM_ YYYY.

5. REGION
7. BPL YES NO
6. MOTHER TONGUE

8. AADHAR NUMBER

9. NEAREST LIVING

YES NO
JNV STUDENTS

10. MOB NO.

11. E-MAIL ID
12. CURRENT ADDRESS

DISTRICT

STATE PINCODE
13. DISTANCE FROM JNV :- KM

14. PARMANENT ADDRESS

DISTRICT

STATE

PIN CODE
15. FATHER NAME

16. AADHAR NUMBER

17. 0CCUPATION i- PRIVATE JOB GOV. JOB

SELF EMPLOYED OTHERS

18. QUALIFICATION

19. E-MAIL ID

20. MOTHER NAME

21. AADHAR NUMBER

22. OCCUPATION :- PRIVATE JOB GOV. JOB

SELF EMPLOYED HOUSE WIFE

23. QUALIFICATION

24. E-MAIL ID

25. ANNUAL INCOME OF FAMILY RS.

 :-BROTHER SISTER
26. SIBLING DETAILS

YES NO
SIBLING IS PART OF JNV:
JNV
REGION:
27. DATE OF ADMISSION (- DD MM YYYY

28. WHETHER STAFFWARD : YES NO

29. HOUSE NAME

JNV
30. PREVIOUS INFORMATION BEFORE COMMING TO
Board Year of T.C.
Registration Class School Name
Passing Number
Number

31. SPECIAL ACHIEVEMENT

 P.M. SHRI JAWAHAR NAVODAYA VIDYALAYA, SHARFABAD, BAGHPAT, UP
FAMILY PROFILE FORM

NAME OF THE STUDENTS:

STUDENTS
CLASS PHOTO

ADDRESS

PHOTO
PHOTO

Signature : Signature :
Father's Name: Mother's Name:
Mob: Mob:

PHOTO PHOTO

Signature: Signature :
Guardian's Name:-. Guardian'sName:-.
Mob: Mob: