Student Image Study Center Code Name of applicant Date of birth Name of mother Name of father Full name of the legal guardian for the orphan Contact details (Please mention mobile number, working email ID linked with Aadhaar card so that OTP can be sent to you for verification on mobile number and email ID linked with Aadhaar card. Aadhaar Card Number: Mobile number linked with Aadhaar: Email ID: Address of Aadhaar card : Correspondence address Present Address OPTIONS FOR RECEIVING SELF LEARNING MATERIALS: From the study centerFrom the office of District Education Officerat his permanent addressat the correspondence addressfrom the Board's officeon Aadhaar card address Selection of subjects for the course Level of Course SecondarySenior Secondary Medium of the course Hindi Compulsory Subjects (Fill the code only) Compulsory Subjects (Fill the code only) Compulsory Subjects (Fill the code only) Compulsory Subjects (Fill the code only) Compulsory Subjects (Fill the code only) ADDITIONAL SUBJECTS ADDITIONAL SUBJECTS Nationality Religion Disability Sex Prior Qualification Category Total Registration Fee Total Payable Registration Fee I declare that the particulars / facts / records / certificates given in the application are true and correct to the best of my personal knowledge and belief. I am well aware of the consequences of furnishing false particulars/ facts. If any particulars/facts/records/certificates given in the application form are found to be false, I will be liable for prosecution and punishment under sections 199 and 200 of the Indian Penal Code, 1960 and any other law in force against me. Will be date Date Signature of the Applicant
