MERRY LAND CONVENT MIDDLE SCHOOL

Rania Road, Mandi Dabwali, Distt. Sirsa. 125104 (Haryana) Ph. No. 01668-227404

(Affiliated to C.B.S.E. NEW DELHI)

SCHOOL LEAVING CERTIFICATE

Book No.

Sr. No. 650

Admission No.

1 Name of Pupil

2 Father's/Guardian's

3 Mother's Name

4 Nationality

5 Whether the candidate belongs to Schedule Caste or Schedule Tribe

Date of first Admission

Date of Birth (in figures)

(in words)

7 Class in which the pupil last studied

8 School/Board Annual Examination last taken with result

9 Whether failed, if so once/twice in the same class

10 Subject studied:

1) English 2) Hindi 3) Maths 4) Science 5) Social Science 6) Punjabi 7)

Whether qualified for promotion to the highest class

If so, to which class (in figure)

(in words)

12 Any fee concession availed of : If so, the nature of such concession

13 Month upto which the (Pupil has paid) school dues/paid

14 Total No. of working days

15 Total No. working days present

16 Whether NCC Cadet/Boy Scout/Girl Guide (Detail may be given)

Games played or extra/curricular activities in which the pupil usually took part

(mention achievement level therein)

18 General Conduct

19 Date of Application for Certificate

20 Date of Issue of Certificate

21 Reason for leaving the school

22 Any other remarks

Signature of

Class Teacher

Checked by

(state full and designation)

Principal

Seal with full address