State Examination Board - Gujarat State

Application form for NTSE - 2019

Confirmation No.: 1115949
PERSONAL INFORMATION OF THE CANDIDATE
Name of the Candidate PUJAN NIRAJ SHAH
Birth Date 13 Jan 2004
Father's Name NIRAJ
Mother's Name MAULIKA
Gender Male
Area in which Candidate Resides Urban
Category General
Disability Status None
Postal address of the candidate for correspondence
21, GITAPARK SOCIETY, B/H GAJANAN HEIGHTS DARBAR CHOKADI, MANJALPUR, Vadodara, Vadodara, 390011
SCHOOl INFORMATION
Name and address of the School/Institution in which studying at Class X level
School Name: DON BOSCO HIGH SCHOOL School DISE Number: 24191300630
District : VADODARA Taluka: VMC CORP Cluster: VADI -16
Village: MAKARPURA WARD 4 Pincode: 390011
Institute Type: Government Aided School Area: 2-Urban
Area in which the school is located: 2-Urban
Type of the institution in which studying at class X level : Government Aided
Address: 21, Gitapark society Darbar Chowkdi Manjalpur
OTHER INFORMATION
Examination Medium (A) At State Level: English (B) At NCERT Level: English
Father's Education Father's Occupation Email-Id
Professional Degree(Engineering, Law, Professional maulikashah27@gmail.com
Medicine, MCA, BA, etc)
Mother's Education Mother's Occupation
Graduation Professional
No. of family members living in the house 5
No. of Brothers: 0 No. of Sisters: 1
At what number is the candidate among his/her brothers and sisters 2
Parental Annual Income Telephone Mobile
5,00,001 To 10,00,000 - 9978111207 9978111207
To be filled in by the Head of the Institution/Gazetted Officer
Certified that:
(1) Master/Miss ͙͙͙͙͙͙͙͙͙͙͙͙͙͙͙͙͙͙͙͙͙͙͙͙͙͙͙͙͙͙͙͙͙͙͘is a regular student of the School/Institution and he/she has secured ͙͙͙͙͙͙͙͘йmarks in
Class IX annual examination i.e. when he/she was promoted from Class IX to Class X. He/she has secured͙͙͙͙͙͙͙͘marks out of͙͙͙͙͙͙͙͘(Candidate must fill
the criteria announced by State/UT).
(2) The particulars given by him/her in the application form have been verified and found in order.
(3) Master/Miss ͙͙͙͙͙͙͙͙͙͙͙͙͙͙͙͙͙͙͙͙͙͙͙͙͙͙͙͙͙͙͘͘belongs to Scheduled Caste/Scheduled Tribe* category as per the records maintained in the
Institution (to be filled for Scheduled Caste/Scheduled Tribe* Candidates only)
Date:

Signature of the Candidate Signature of the Headmaster/ Headmistress/ Principal (with Seal)