Applica M F. Form No. Tick the appropriate box. Name: Sex: Ph. No: Ph. No:

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1 Form No. Applica pplication For orm ODM International School. Sishu Vihar, Patia, Bhubaneswar ODM Public School. Sishu Vihar, Patia, Bhubaneswar ODM Public School. BDA Branch, Bhubaneswar ODM World School, Dhenkanal Tick the appropriate box Name: Sex: Class School No. M F y) Stream Session Ph. No: Science Commerce Plan (For Sr. Sec. Only) D.S Res. Ph. No: www. odmis.org,

2 APPLICATION FOR PROVISIONAL ADMISSION Subject to fulfillment of terms and conditions of the School Instruction to fillup this Form : Information must be filled in with legible hand writing in Capital letters only except ID. Recent passport size coloured photograph of the candidate, Parents & Local guardians should be affixed at the space provided in the form. Mention NA against the columns not required. Please paste photograph DO NOT STAPLE 1. ADMISSION SOUGHT FOR THE CLASS : (Put Mark) (A) Primary Section (B) Secondary Section (Nur. to Class-V) (VI to X) a) ODM I.S. a) ODM I.S b) ODM P.S. b) ODM P.S. Std. (C) Sr. Secondary/+2 Sec. a) CBSE (Sc.) b) CBSE (Com.) c) CHSE (Sc.) ODM I.S. ODM P.S. Student 2. FOR SENIOR SECONDARY / +2 SECTION ONLY : (A) SUBJECT OPTED FOR : (Please the appropriate Subject) CBSE (Sc.) : a) Eng. b) Phy. c) Chem. d) Maths e) Comp. Sc. Phy. Edn. Bio. N.B. : CBSE Science student may opt. for Phy. Edn. Economics as 6th subject. Commerce: a) Eng. b) Accountancy c) Business Std. d) Eco. e) Comp. Sc. Phy. Edn. Maths CHSE (Sc.): a) Eng. b) MIL(O/A.E) c) Phy. d) Chem. e) Maths f) Bio. (B) CATEGORY : Day Scholar Residential with Coaching 3. PERSONAL DATA OF STUDENT : Surname First Name Middle Name D D M M Y Y Y Y Date of Birth : (in words) : Sex : Female Male Religion Nationality Category : SC ST OBC GEN Mother tongue Student s Passport No Date & Place of Issue Languages spoken at home (if any) Expiry Date 4. ADDRESS : PRESENT Plot No/Street No & At. PO PS City PIN Code Country HOME : Tel# Fax# Mob# PERMANENT Plot No/Street No & At. PO PS City PIN Code Country HOME : Tel# Fax# Mob#

3 5.(A) ACADEMIC RECORD : Name of the School last attended City State Country From To Reason for leaving (B) SCHOOL PERFORMANCE : Aggregate percentage/grade in the last Examination (True copy of the marksheet of qualifying Exam / SA-I must be submitted) 6. PROFICIENCY RECORD Please provide details of achievement in : (Evidence in support of Performance) Sports Performing Art, Music, Dance, Drama, Debates etc. Position or responsibility held in school or community Other 7. PARENTS /GUARDIAN S INFORMATION : Father s Name Age Nationality Guardian s Name Age Nationality Mother s Name Age Nationality Student residing with at present : 8. PROFESSION/OCCUPATION : FATHER/GUARDIAN Designation Annual Gross Income DO NOT STAPLE Father/Guardian MOTHER Designation Annual Gross Income DO NOT STAPLE Mother

4 9. LOCAL GUARDIAN S INFORMATION : (For Residential Students only) 1 Local Guardian s Name Age Nationality Education/University Designation DO NOT STAMPLE Local Guardian-1 Annual Gross Income Local Guardian s relationship with Student 2 Local Guardian s Name (If necessary) Age Education/University Nationality Designation DO NOT STAMPLE Local Guardian-2 Annual Gross Income Local Guardian s relationship with Student 10. TRANSPORTATION : For Day Scholar Student only (If permitted please apply in a Scheduled format) Interested for school transport; Yes No If Yes, your location/area City Approximate distance from the school km. 11. EMERGENCY CONTACT : Please indicate whom to be contacted in case of emergency Name... Contact No... Name and address of the person to whom details of payment of fees be sent. Name... Address...

5 12. DECLARATION : BY THE PARENTS GUARDIAN I/We certify that the information furnished in this form is true to the best of my knowledge and belief. False or incorrect information if supplied in this application can jeopardize selection and enrolment. I have gone through the prospectus and having satisfied myself want to get my son/daughter/ward admitted in standard / class... I... Father/Mother/Guardian of... do hereby declare that I will cooperate with the school Management by following the instructions of the authorities in terms of financial, academic and administrative policies from time to time. I will abide by the decisions of the Management if taken against my ward for deviation of rules and regulations of the school/hostel. Sign. of Mother... Sign. of Father/Guardian... Date :... Date : UNDERTAKING BY THE STUDENT (FOR STD. XI & XII ONLY) : I... a candidate for admission in Std-XI / XII for the session... as day scholar / residential do hereby undertake that I will abide by the rules and regulations of the school/hostel as applicable from time to time by the school authorities. I will accept the decisions of the Management for any of my activities going against the discipline dignity of the institution. I, as a disciplined student, will take care of the school/hostel properties. Date DOCUMENTS TO BE SUBMITTED AT THE TIME OF PROVISIONAL ADMISSION : a. True copy of the marksheet / Progress report of the last qualifying examination. b.true copy of the certificates of merit, if any. c. Birth certificate (photocopy) or Passport copy or X th Board Certificate d.photographs : Students (four nos), Parents (two nos), Local guardians (two nos), Family photo (two nos - for Primary Section only). e. Conduct certificate from the Head of the institution last attended f. Registration Fee. Receipt g. Copy of caste certificate wherever applicable. h. Xerox copy of admit card of qualifying exam. ( Provisional Adm. can be regularised after submitting the original TC/SLC ) 15. REFERENCES : (DETAILS OF TWO PERSONS WHO CAN VOUCH FOR YOU NOT RELATED TO YOU) a. Name Occupation Tel # Address PIN code Country b. Name Occupation Tel # Address PIN code Country FOR OFFICE USE ONLY 1. Application Fee paid : Yes No 2. Appeared Admission Test : Yes No 3. Qualified in Admission test : Yes No 4. Recommended for admission in as Boarder / Day scholar. 5. School registration No: 6.Received(Rs/ USD) vide Cash/ Cheque/DD No. towards registration. Receipt No. Verified By Admission I/C Principal

6 At - Sishu vihar, Infocity Road, Patia, PO - KIIT, Bhubaneswar Phone No , ,

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