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 State Council of Educational Research and Training, Chhattis garh
APPLICA FORM
NATIONAL TALENT SEARCH EXAMINATION (NTSE) Stagcl, 2018 -19
( For the Students Studying in Class x )
Last date 25 Aug 20 I 8 (s ubmit ln yow S choo D Exam date : 04 Nov. 2018
t<taer en] 3TFiFd
State Code Year Cenlre Code Serial Number
Roll No. 3 3 1 9 III cfiqr"ff 6T crs+J
Date of Birth
I
fr- II Dale Month

rIII Studying
in Class
eron ot qH,
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l. , Candidate's Name (In English) ifiFrlrtrrd
.2. Father's Name (In English)
'3. ' Mother's Name (In English)

Cross (x) only one of the appropriare box 4,5,6,1,8,11,12 and 22 (sqfud 96 ff r3ri { o.rs tx) 6r fu€ arri) .

4. Sex : Male I Female 2 ' 5. Residential Area: Rural (Trfiur) Urban (rrrft) 2

6. . Do you belong to OBC as per Central List ? E @

If yes,Name the State and Name ofthe OBC
7. Cast category: GEN I OBC 2 SC 3 ST 4

& 'Disability Statu5,rft56frr61 6T FDr{ : (l) Types of Disability (a) BLV (4) Types of Disability (d) AID
(lnstruction/Coding plan ofpage-2) (2) Types ofDisability (b) DH (5) Types of Disability (e) MD

* Attach ce rtificates ifyou

(3) Types of Disability (c)

be lon gs to OBC (as oer Central List) /

LD

/ ST / Disabilitv
(6) None ofthese

Im paired
t**l
9. Postal address for corres ondence .10. Name & address ofSchool in which stud ying at X level

Pin Code

11. Ttpe ofSchool in which study

II Pin Code

at Class X 12. School located

Govemment / {Ir{Eftq Private aided / ircll irSErr cr< Rural (Trfrq)
Local Body,hrrftq ft6rq Private Unaided/cirTT..1-< erg<n vrw Urban (vrQ)
* For filling in boxes in Sr. No. 13 to l7 see Code No. mentiotred below (page no.2)
13. Medium of examination: English Hindi 14. Father's education
E
15.
tFather's occupation : 16, Mother's education :
E 17. Mother's occupation
E
t!. No.of family members 19. No.ofbrothers :
E 20. No. of sisters
E
21. -{t what number is the candidate among his/her brother and sisters (rrr{, e-6=il

22. Parental annual income: Up to 2,00,000 I 2,00,001 to 3,00.000

n qfuilpff 61 6-q fr@r)
2 3,00,001 to 5,00,000
E3
5,00,001 to 10,00.000 4 More than 10,00,000 5

23. Mobile No II e-mail

Datc. --l-/20 I 8, Signature of Parent's: , Sigtrature of Studert's:

To be filled in by the Head ofthe Institution
Certified that Master/Mis... ............................ ............, Son/daughter of Shri /Smt............ ...... .
is regular student of Class X in this School. He/she belong to ...... ...............(GEN/OBC-as per Central
List/SC/ST)
as per the records mainrained in the Insritutions.

Signature with serl

Head ofthe Institution
 Page - 2

IIstruction / Coding Plan

Read Instruction Carefully Before Filling Up To The Application Form.
1 . Use Only Blue Or Black Ball Point Pen. Write tn Captital Letters.Do Not Mark Or Write Out Side The Boxes.

2. Cros (x) only one ofthe appropriate boxes in items nos 4,5,6,7,8,11,12 and 22.
3. Please write code number in items nos 13,14,15,16 and l7 as given overleaf
4 lt is the responsbility ofthe candidate and the princpal of the school to deposit the filled in form with the state
concemed officer before the last date. No request for condonig delay in submission will be entertained whether it is due
to the fault ofthe candidate or the headmaster/principal ofhisfrer institution.

5. Incomplete or defensive applications are libale to be rejected.

6. Disability status:
Ttpes of Disability
(a) blindness and low vision; BLV
(b) deafand hard ofhearing; DH
(c) locomotor disability including cerebral palsy, leprosy cured, dwarfims, acid attack vixtim and mscular
dystrophy LD
(d)
(e)
autism, intellectual disability, specific learning disability and mental illness
@
multiple disabilities fiom amougst persons under clauses (a) to (d) incliding deaf-blindness in the posts indetified
for eaach disabilites Mt)
7 Code No. for Sr. No. 13,14,15,16,17
EDUCATION OF FAT}IER OR MOTHER Code OCCUPATION OF FATHER OR MOTIIER- Code

No Formal Education I Professional, I

Up to Primary 2 Executive and Managerial Worker 2

Upper Primary 3 Clerical 3
Secondary 4 Business 4
Senior Secondary 5 Agriculture and fishery 5
Gnduation 6 Production & Transport 6
Post graduation 7 Operators and Labourer 7
Doctoral 8 Not employed 8
Professional degree (Engin€ering,Medicine,MCA,IrBA,t"aw erc 9
MEDIUM OF EXAMINATION : English - 13
Hindi - t5

* Types ofschool / Institutions (refer to items

no.l l)
Covernment : A Govemment School is that which is run by the state Covemment or public sector undertaking
or an Autonomous organization completely financed by the Covemment.
Local Body: : A local body school is that which is run by panchayati Raj and Local Body institution such Zila
Parichad, municipal Corporation Municipal commttiee.
Private Aided : A Privad aided school is that which is run by an individual or a private organzation and receives
grant from Govemment or local body
Private Unaided : Private unaided school is that which is managed by an individual or a private oranization
and
does not receive any gant from govemment or local body.

-- 00 --
 State Council of Educational Research and Training, Chhattisgarh

ADMISSION CARD
NATIONAL TALENT SEARCH EXAMINATION (NTSf,) Stage.I,2018 -19
Exam date : 04 Nov 2018

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