APPLICATION FORM for Young Scientiest Programme of YUva VIgyani KAryakram -

"YUVIKA-2019" of Indian Space Research Organisation

Personal Information Application reference number:56854

Name of Student : JAYASURYA.M.S Date of Birth : 28-11-2003

Gender : Male Name of the Parent/Guardian. : SELVAM.M

Communication Details

Present Address

House No./Street : no 14/A,kattunaicker street Address Line 2 : kadachanendhal

City : MADURAI State / Union Territory : TAMIL NADU

Postal / Pin Code : 625107

Permanent Address

House No./Street : no 14/A,kattunaicker street Address Line 2 : kadachanendhal

City : MADURAI State / Union Territory : TAMIL NADU

Postal / Pin Code : 625107

Contact Information

Mobile Number:9865921550

Email Address:selvammuniyandi5@gmail.com
Academic Information

Any membership in Science Club/Space Club if Yes please give the details of
membership:No

Name of School with complete Postal Address: VALLABA

VIDYALAYA,THIRUVILANPATTI,ARUMBANUR,MADURAI.

School where the school is located : TAMIL NADU

Whether the school is located in a Panchayat Area(Yes/No): Yes

Panchayat Name: MADURAI EAST

Name of the Board of Education(State/CBSE/ICSE/International/Others).: CBSE

Marks Secured/Total Marks in 8th Std:

Marks Obtained: 389.0 Total Marks: 389.0 % of Marks: 100.0

Give Details: Prize in any school individual extracurricular activity(Elocuton/Debate/Essay

Writing,Science quiz,Computer modeling,Scientific prototype model making,etc.,) at
District/State/National/International Level(The higher level will be considered for
weightage)

Name of the International

Sl.No District Level State Level National Level
Activity Level

1)

2)

3)

4)

* Winners of District/State/National/International Level sports activities (The higher level

will be considered for weightage)

Type of International
Sl.No District Level State Level National Level
Sports Level

YOGA
COMPETITIO Third
1)
N

2)

MINI
3) Second
MARATHON

4)
Scouts and Guides/NCC/NSS Member, if any: No

Declaration of Parent or Guardian

I, being the parent/guardian of the student, give consent for him/her to attend the Young
Scientist Programme or "YUva VIgyani KAryakram - YUVIKA-2019 " if selected.

Signature of the Parent/Guardian

Declaration of Student

I hereby declare that the information furnished above is correct to the best of my
knowledge.

Signature of the Student Attested by

Signature of the Head Master/Principal(with Seal)

Date:

It is certified that Kum/Kumari _________________________________________ is studying

in ___________________________________________(School) and the school is located in
the ________________________________________ (Panchayat) area.

Signature of the Head Master/Principal(with Seal)

Date:

To complete the registration process follow the following instructions :

1. You are advised to download and print the filled application form.
2. The printed application form must be complete in all respects duly signed by the
candidate, Parent/Guardian and Head Master/Principal of the School.
3. Scan the signed application form and upload the same by logging into YUVIKA webpage
using your registered E-mail ID and yuvika password.