APPENDIX
FORM-I
SELF DECLARATION CUM APPLICATION FOR GRANT OF RECOGNTION OF
SCHOOL
See sub-rule(1) of rule 14 of Andhra Pradesh Right of Children to Free and
Compulsory
Education Rules,2010.
To
The District Educational Officer (through Mandal Educational Officer Concerned)
District………..
Andhra Pradesh.
Sir,
I forward herewith a self declaration regarding compliance with the norms
and standards prescribed in the Schedule of Right of Children to Free and
Compulsory Education Act, 2009 and an application in the prescribed proforma
for the grant of recognition to ___________________ (Name of the school) with
effect from the commencement of the academic year ____________.
Enclosure: Yours faithfully,
Chairman of Managing
Committee/Correspondent
Place:
Date:
A. School Details
1. Name of the School
2. Academic Session
3. District
4. Postal Address
5. Village/City
6. Mandal
7. Pin Code:
8. Phone No.with STD Code
9. Fax No.
10. E-mail address if any
11. Nearest Police Station
B. General Information
1. Year of Foundation
2. Date of First Opening of School
3. Name of Trust/ Society
4. Registration number of Trust/ Society
(enclose copy of document of registratior)
5. Whether there is proof of non- proprietary
character of the Trust/ Society supported by
the list of Member with their address on an
affidavit in copy
6. Name official address of the Manager/
President / Correspondent
Name:
Designation:
Address:
Phone (O):………………
(R):……………….
Email Address
7. Total Income & Expenditure during last 3 years surplus/ deficit
Year Income Expenditure Surplus/ deficit
C. Nature and area of School
1. Medium of Instruction
2. Type of School (Specify entry & exit Classes)
3. If aided, the name of agency and percentage
of aid
4. Teaching posts created
Of the posts in the
Number of posts
previous column no. of
Name of the Post created by the
posts admitted to Grant-
Management
in-Aid
i)Headmaster
ii)School Assistant
iii)Secondary Grade Teacher
iv)PET
v) Language Pandits
vi) Art/Music/Computer
Teachers
5. If the School recognized
6. If so, by which authority
Recognition number
7. Does the school has its own building or is it running in
a rented building
8. Type of building(Pucca, Partially pucca, Kucha, Tent)
9. Whether the school buildings or other structure or the
grounds are used only for the purpose of education
and skill development?
10. Total area of the school
11. Built up area of the School
12. Play area in the premises of the Schools (in Sq.Mts.)
13. Boundary wall/Fencing
14. Whether School is under obligation to provide free
education to specified number of children on account
of having received any land, building, equipment or
other facilities, either free of cost or at a concessional
rate from the State Government, Central Government
and local authority
15 If Yes, enclose copy of the document
D. Enrollment Status
No.of Students Disadvantaged Group
No.of Boys Girls Total Orphans HIV CWSN SC ST BC Minorities
Sl.No. Class
Section Affected
/Infected
1. Pre-
Primary
2. I
3. II
4. III
5. IV
6. V
7. VI
8. VII
9. VIII
10. IX
11. X
E. Infrastructure Details & Sanitary Conditions
Sl.No. Rooms Numbers Average Size
1. Classroom
2. Office room- cum store room-cum- Headmaster room
3. Kitchen-cum-store
4. Science Lab
5. Library room
6. Sports & Games room
7. Computer Lab
F. Other facilities
1. Whether all facilities have barrier free access
2. Teaching Learning Equipment( attach list)
3. Sports & Play equipments (attach list)
4. Facility books in Library
Books (No. of Books)
Periodical/News Papers
5. Type of number of drinking water facility
6. Sanitary Conditions
(i) Type of W.C & Urinals
(ii)Number of Urinals/Lavatories Separately for Boys
(iii) Number of Urinals/Lavatories Separately for Girls
7. Electricity
G. Particulars of Teaching Staff (Details of each teacher separately)
1. Teachers in Primary School
Teacher’s Name Father’s Name Post working in Whether the teacher is
(1) (2) (Designation) Working in Grant-in-
(3) Aid Post
(4)
Date of Birth Date of Academic Professional
(5) Appointment Qualification Qualification
(6) (7) (8)
Subjects studies Teaching Classes & Trained or Untrained
a. Degree Level Experience Subjects (12)
b. P.G.Level (10) handled by the
c.B.Ed.Methodologies Teacher
(9) (11)
Scale of Pay Gross Salary per Whether salary
(13) Month is paid through
(14) Nationalized
bank to the
account of the
teacher
(15)
2. Teachers in Upper Primary School
Teacher’s Name Father’s Name Post working in Whether the teacher is
(1) (2) (Designation) Working in Grant-in-
(3) Aid Post
(4)
Date of Birth Date of Academic Professional
(5) Appointment Qualification Qualification
(6) (7) (8)
Subjects studies Teaching Classes & Trained or Untrained
a. Degree Level Experience Subjects (12)
b. P.G.Level (10) handled by the
c.B.Ed.Methodologies Teacher
(9) (11)
Scale of Pay Gross Salary per Whether salary
(13) Month is paid through
(14) Nationalized
bank to the
account of the
teacher
(15)
3. Teacher in High School
Teacher’s Name Father’s Name Post working in Whether the teacher is
(1) (2) (Designation) Working in Grant-in-
(3) Aid Post
(4)
Date of Birth Date of Academic Professional
(5) Appointment Qualification Qualification
(6) (7) (8)
Subjects studies Teaching Classes & Trained or Untrained
a. Degree Level Experience Subjects (12)
b. P.G.Level (10) handled by the
c.B.Ed.Methodologies Teacher
(9) (11)
Scale of Pay Gross Salary per Whether salary
(13) Month is paid through
(14) Nationalized
bank to the
account of the
teacher
(15)
4. Headmaster/ Principal
Teacher’s Name Father’s Name Post working in Whether the teacher is
(1) (2) (Designation) Working in Grant-in-
(3) Aid Post
(4)
Date of Birth Date of Academic Professional
(5) Appointment Qualification Qualification
(6) (7) (8)
Subjects studies Teaching Classes & Trained or Untrained
a. Degree Level Experience Subjects (12)
b. P.G.Level (10) handled by the
c.B.Ed.Methodologies Teacher
(9) (11)
Scale of Pay Gross Salary per Whether salary
(13) Month is paid through
(14) Nationalized
bank to the
account of the
teacher
(15)
H. Curriculum and Syllabus
1. Details of curriculum & Syllabus followed in each class (up to VIII)
2. System of pupil assessment
3. Whether pupils of the School are required to take any Board exam
up to class 8?
I. School fee (per Annum)
S.No. Classes Tuition fee Special fee Other fee if any
1. Pre-Primary
2. I
3. II
4. III
5. IV
6. V
7. VI
8. VII
9. VIII
10. IX
11. X
J. Neighbourhood area for purpose of section 12(c) of the Act.
Within 1 Km Within 3 kms
Name of the Habitation General Population Name of the General
/Locality Habitation Population
/Locality
K. Certified that the School complies with the Fire Safety Rules, Municipal by-
laws and Traffic Regulations.
L. Whether School has constituted Parent Teacher Association (PTA) as per
G.O.Ms.No.246 ? if so, attach the details along with the minutes of the last two
meetings.
M. Certified that the School has also submitted information in the Data
Captured Format of District Information System of Education (DISE) with this
application.
N. Certified that the School is open to inspection by any officer authorized by
the appropriate authority;
O. Certified that the School undertakes to furnish such reports and information
as may be required by the District Educational Officer from time to time and to
comply with such instructions of the appropriate authority or the District
Educational Officer as may be issued to secure the continued fulfillment of the
condition of recognition or the removal of deficiencies in working of the School;
P. Certified that records of the School pertinent to the implementation of this
Act shall be open to inspection, by any officer authorized by the District
Educational Officer or appropriate authority at any time, and the school shall
furnish all such information as may be necessary to enable the Central and/ or
State Government/ Local Body or the Administration to discharge its or his
obligations to Parliament/ Legislative Assemble of the State/ Panchayat/
Municipal Corporation as the case may be.
Place: (Signature)
Date: Secretary cum Correspondent
…………………….………School
