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APPLICATION FORM

STATE LEVEL NATIONAL MEANS - CUM - MERIT SCHOLARSHIP SCHEME EXAMINATION-2013(For the Students Studying in Class VIII)

Read the instruction carefully given on the next page before filling the application form.You may take the help from your teacher / parent for filling up the application form.- Date of Examination : 02.12.2012 (Sunday)- Name & Address of the Agency for conducting N.M.M.S.S. Examination : S.C.E.R.T. Bihar, Mahendru, Patna-6- Name of the State / UT : Bihar(where the candidate is studying in class VIII as a regular student)

State Level 12 digit Roll Number

Space for thePhotograph

(Passport size)That must be

Black & WhiteThe Photograph should

be attested by theHead of the Institution /

Gazetted Officer

Scheme Code State Code Year Distt. Dode Centre Dode Serial No. (Office to fill) Class Date of birth

3 2 0 1 3Date Month Year

08

1. Name of the Candidate (Do not write Miss/Master)

2. Father's Name (Do not write Mr. / Dr. / Prof.)

3. Sex 4. Area to which candidate resides 5. Caste category of candidate 6. Disability Status of Candidate

Male Female Rural Urban General S.C. S.T. E.B.C. B.C. OrthopedicB.C. Hearing LowVision

Blind None

1 2 1 2 1 2 3 4 5 6 1 2 3 4 5

Female7. Postal address for correspondence (Do not write Father's or your name)

Pin Code

8. Name and address of the institution in which the applicant is studying at Class VIII level

Pin Code

9. 10.Type of the institution in which studying at Class VIII level (See definition overleaf*) Area in which the school is located

Govt.1 Govt. Aided2 Rural1 Urban2

11. Medium of examination 12. Father's Education 13. Father's Occupation

14. Mother's education 15. Mother's occupation 16. No. of family members living in the house

17. Number of brothers 18. Number of sisters 19. At what number is the candidateamong his/her brother and sister's

20. Parental annual income

Up to 50,000 50,001 to 100,000 100,001 to 1,50,000 1,50,001 to 2,00,000 2,00,001 to 2,50,000 More than 2,50,000 More than 5,00,000

21. Telephone

STD Code Phone/Mobile No. E-mail address22.

1 2 3 4 5 6 7

To be filled in by the Head of the Institution/ Gazetted OfficeCertified that :

Master/Miss. ................................................................................. is a regular student of this School/Institution and he/she has secured % marks in the Class VIIannual examination i.e. when he/she was promoted from Class VII to class VIII. He/she has secured ....................................... marks out of .................................(Candidate must fulfill the criteria announced by S.C.E.R.T, Patna)The particulars given by him/her in the application form have been verified and found in order.Master/Miss ..................................................... belongs to S.C./ S.T./ E.B.C./ B.C./ Female B.C./ Disabled Category as per the records maintained in the Institution. (to befilled for reserve category only..........................................................

Date

(1)

(2)(3)

............................................................................................

Signature of the candidate

Note: Application directly send to SCERT shall not be accepted.

..............................................................................................Signature of the Headmaster/Headmistress/ Gazetted Officer

With Seal

(See Instructions overleaf)

Education of Father or Mother(Refer to item 12 & 14)

EducationNo Formal education

Up to Primary

Upper Primary

Secondary

Senior Secondary

Graduation

Post Graduation

Doctoral

Professional degree (Engineering, Medicine,MCA, MBA, etc.)

Any Other

11

12

13

14

15

16

17

18

19

20

1

2

3

4

5

6

7

8

9

10

Code

No. 13 & 15)

Tick (P) only one of the appropriate boxes in item nos. 3, 4, 5, 6, 9, 10 & 20

11, 12, 13, 14 and 15 as given below.

GOVERNMENT AIDED A Government Aided School is that which is run by local body and aided by State Government/Central Government

Code (Refer to Item No. 11)