Registration Performa for Inspire award 2011 1

							                                                                               Page No. 1

                                                 INSPIRE AWARDS – 2011                                                                               Affix Passport
                                      (Innovation in Science Pursuit for Inspired Research)                                                           Size Photo
                                               [ An Initiative of DST, Govt. of India ]


                                                    REGISTRATION FORM
1. Name of Student :



2. Class of Study (2010-2011) ..................................................

3. (a) Full Name of School :



(b) Name of the Principal /Headmaster / Headmistress.




(c) Address of School : .....................................................................................................................................
..........................................................................................................................................................................
..........................................................................................................................................................................

(d) Phone No. of Principal /Head Master /Head Mistress (Office) .............................(Res.)..........................

4.(a) Father’s /Mother’s Name of Student :                                                                  Mobile ................................................




  (b) Phone No. (Residence) .........................................                                       Mobile ...............................................

5. Gender :                                    Male                                             Female


6. Date of Birth
                                               Date                          Month                              Year

7. (a) Category                                SC                       ST                      OBC                       General

  (b) Known Language :                         English                              Hindi                              Other .....................................

8. (a) Overall Marks Scored in last two year (2008-2009)............................................................................
                                                                       (2009-2010)............................................................................
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(b) % Marks scored in science subjects                                (2008-2009).............................................................................
                                                                       (2009-2010)............................................................................


(c) Extracurricular activities – place in school ............................................................................................


9. Any other Achievement (Certificate from School Principal to be attached to the effect)
.....................................................................................................................................................................


Hobbies                 i) ...............................................                      ii) .........................................................


10. Awards / Prize received, if any : i) ...................................................................................................
                                                            ii) ................................................................................................
11. Is he/She willing to take in the INSPIRE AWARD Exhibitions at the District Headquarters/State level


                                                                                                            Yes                                 No
                                                                                                            (Tick mark the option)




Signature of Parent/ Guardian                                                                               Signature of the Applicant
                                                                                                            Class .......................................


Certified that the above facts are true, as per the School records and to our best information. We recommend
this student for the INSPIRE Award.


Date:
                                                                        Signature of the Principal / Head Master / Head Mistress
                                                                        Seal of School


[Kindly submit the ‘Registration Form’ to the respective State Education Department through the
                                                                                                    District Education Officer of the State.]