APPLICA DA BIR TH IN SCHOOL RECORDS TIFICA TE OF QUALIFICA I GORt No 8532011GEdn G Dt 1032011 GEdn Dept II GO RtNo 22812011G Edn Dt 180611GEdn G DeptTo be r ID: 950453
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APPLICA TION FOR CORRECTION OF DA BIR TH IN SCHOOL RECORDS TIFICA TE OF QUALIFICA I) G.O(Rt) No. 853/2011/G.Edn. (G) Dt. 1.03.2011 (GEdn.) Dept. II) G.O. (Rt)No. 2281/2011/G. Edn. Dt. 18.06.11G.Edn. (G) Dept(To be routed through the Head of the School in which the applicant last studied or is studying)2. Details of Certificate in which3.Date of birth4.State whether the present application5.If not, details of Government Ordercondoning delay, in relaxation to Rule (Original to be enclosed)6.Documentary evidence produced for7.Name and details of the officer who8.Details of application fee remitted.9.State whether the person has appliedi.Name ......................................... ......................... .......... ...ii.Address ..... .. ... ... PIN ...........................Revenue District . ..... .............................................iii.Wh
ether belongs to SC/ST :Yes / Noiv.Name of the parent/guardian .................................................................v.Place of birth ......... ............................. Department ................................................................................... Official Address ............................................................................Book/Card No.: ................ Reg. No.: .......................Year : .................Existing : .....................................................................................................Proposed : ........................................................Yes/NoG.O. (Rt.) No. ................... Dated ..... ....No. and Date of issue of the Birth Certificate ...............................................Name of Revenue District ...........................................................................Amo
unt Chalan No . .. Date ..Name of Treasury . Mobile Phone No. of applicant (in block letters) Certified that the details furnished by the candidate have been verified with school records and found correct. Hence I I do hereby declare that the details furnished above are true to the best of my knowledge and belief.Name and signature of the Guardian Name and Signature of the Applicant IDENTIFICA TION CER TIFICA TE FROM (Only if the name of applicant dif No. Date Certified that the male/female child born to Shri. ............................................................................ ..(address) on ............ .......... (Date of Birth) andwhose birth was registered at ..................... ... Grama Panchayat/Municipality/Corporation with(here enter the full name and address of the person whose date of birth is to be alt
ered). The said person and theExtract of Admission Register with Admission No. ..............................................................................the Headmaster .............................................................................................................. a10 STATEMENT SHOWING THE PARTICUALRS OF EDUCATIONAL INSTITUTIONS ATTENDED FROM STD I TO Xaddress including RevenueStandard to(1)(2)(3)(4)(5)(6)(7) Name & Signature of the Headmaster/Headmistress Place :Date :Office SealPlace :Date :Date of ̱¤° °¥²Ì²Ò°²á À¯ý¯¦¹ Û¯¦¯¾²Ò°¸ ª«»£¯¤ °Ü¶Í«Äà µ..Ü üȹ 6 ¸° 3 ½¯¥¹ ̱¤° °¥²Ì²Ò°²á ¯æ¯¤° 15 ªÜ¬Ì°¹/ ¸³à ª°È°² ¶«¬¹ 15 ªÜ¬Ì°¹ Ò¯Þ · ¯§¥°°¾²¶«¬¹ £ÜÔ°¾²ÒªÜ ¯§¯££¯Ô¯¾²Ò°¸ ܾ¯¥°µú ½¶» Ì¥ª¸ ®¯¥¯¶¾Ê¯¸. °¯¤° ¯²ª°»¯¢»¯½È¦°, ª. µ½¶È¦°¤Ý¸ (¸) °¥²ªÐ²¥¹ Ò ° ¤²µ¤²¹ ÜÈ°ý°¾Ý°µú¤²¹ ÜÔ¸ ®°¹ £ÜÔ°¾¹. ¸.Þ.° ªµ¥ °Å ߯ ¸³¨²¨²¶¤²¹ ³ÜË£
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