2018Please complete the following information in CAPITALS :fuse bl«e/bi.ck Ban pint pent

Dakshana RolINo: 2 6 B 3 4 { 5 5 g 5 q JNV Roll No

L©s} Name+Firsf Name twiddle Name

Jawahar Navodaya VidyalayaSchool Name

Sort kcGir N@attrDistrict Name

Date of Birth 1 9 0 9 Q Q Q Gender: M]g]IFE](Tick appropriate)

Category :IGEN=1 0BCii211 ST D PD ; YES [] NOjg (Tick appropriate)

Test centre code [glli11151Applying for : Engineering [] MedicalE](Tick appropriated

As per class 10 CBSE Registrationd'

The Dakshana FoundationApplication to Become a Dakshana Scholar

Dakshana Scholars are brilliant, but impoverished students who aspire to attend a premierengineering/medicalcollege, but cannot afford to be coached professionally by a world-class coachinginstitute. The Dakshana Foundation provides comprehensive scholarships to gifted/impoverishedadolescents who meet our criteria. These scholarships include 100% of coaching fees and books. In orderto be eligible to apply for becoming a Dakshana Scholar, you must be invited to appear for and qualify in theNavodaya Dakshana Selection TestjNDSTI. The decision of Dakshana in this regard isfinal.

Dakshana reserves the right to validate the information provided through various sources including NVSrecords, Principal and school staff interviews, peer. neighbours, school alumni and direct verifications.Should any information be found to be willfully falsified, Dakshana reserves the right to deny acceptance asa Dakshana scholar and/or terminate the scholarship at anytime after it has started.

Ihereby do attest that allof the information submitted in this application is correct and authentic and that Imeet allof the criteria mentioned to apply for being named a Dakshana Scholar:

Rd.. ]dsw.⑩..Student Signature Date r

Page I of 4

PLEASE DO NOT LEAVE ANY BLANK ANSWERS TO THE QUESTIONSRELEVANT

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Father/Guardian's FulIName Father's Education Levelje.g. B.A, 12th Pass, 10th Pass, Illiterate etc.I

Father's Occupation

[] EmployedEmployer's/ Organisation Name

g FarmerAcres/Bhiga jlt own lands

[] BusinessSpecify- IShop, Cart. Home business etc.)

[] OtherSpecify details jfor e.g. Labour/ Doctor/ Lawyer etc

Smt.,rl..H .....ihklih ......O.eg........Mother's/Guardian's FulIName Mother's Education Level

je.g. B.A, 12th Pass, 10th Pass, Illiterate etc.I

Mother's Occupation a Housewife

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[] Fa rmer X:;i;giiiiifl;iii;i;i;'i;Hal

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Other Adult/s lrlthe household :(Please mention details ol grandparents/uncle/older siblingsliv

Rela bon Occupation

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hop, Cart. Home business etc.) Typical Daily income

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your mother can read and write

iiness etc.) l#ical Daily income

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ng in your housed

TypicaIMonthly income

TotaIApproximate Value of Total Household is your parents' homeAlIHousehold Assets . Cash Savings owned or rented?IExcept Household Cash Savings)

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Month'26.Q.'ol)Ifees" ... You live in: E]]i] RuraIArea [] Urban area [] Semi-urban area (Tick appropriated

Are you disabled or physically challenged ? Yes [] No 1i]]]

If yes, please specify the physical disability.

Please answer the following with a Yes or No. Does your family have g

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Page 2 of 4

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(You can use this farm or a separate piece of paper. Please submit the essay in your ownhandwriting)

StandardAggregateMarkstout of 500*)

ScienceMarks

(oul of 100)

MathsMarks

(out of 100)

10thjPTll ....ZaJ.?-ig ....484.. .9..6....-.. .........9...8.

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Leave blank where results are awaited.

* 500 marks include marks for Maths, Science, SocialScience, English and a Regionallanguage