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GENERAL INFORMATION Ram Ratna International School is the second project by Uttan Vividh Lakshyee Shikshan Sanstha. Ram Ratna International School is affiliated to the University of Cambridge International Examination. U.K. Admissions are open for the year 2013-14 only for the following grades: Pre-Primary : Nursery, Jr. KG & Sr. KG Primary : Grade I to V Middle School : Grade VI to VIII Admission Procedure: Age Eligibility:- Applicant student is expected to be born in the period shown against the respective grade for which admission is sought- Nursery 2 and ½ years and above as on 1 st June 2013 Jr. KG. 3 and ½ years and above as on 1 st June 2013 Sr. KG 4 and ½ years and above as on 1 st June 2013 Grade 1 5 and ½ years and above as on 1 st June 2013 (School will strictly abide by the age criteria of Nursery, Jr. KG., Sr. KG. & Grade 1) Registration: The registration forms are included in the Admission Information Kit available at the school office from 9.00 am to 1.00 pm (Monday to Friday) or can be downloaded from the school website and submitted online. Timings on Saturday: 10 am to 1 pm (except 4th Saturday) A duly filled form obtained from the school website is to be submitted with the non-refundable, non-transferable registration fee of ` 500/- within 7 days from the date of issue of the form or the last date given. PLEASE NOTE THAT THE REGISTRATION AND PAYMENT OF THE PROCESSING FEE OF ` 500/- DOES NOT GUARANTEE ADMISSION TO RRIS. Personal Interaction with the PRO and the Principal Based on the personal interaction, entrance test (for grade II For all matters related to admission, the decision of theAdmission Selection Committee will be final. Parents of selected students will interact with the Admission Selection Committee. onwards) and other criteria, the school reserves the right to admit any student who is found eligible for admission or refuse admission without assigning any reason.

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A Global Educational Initiative of Uttan Vividh Lakshyee Shikshan Sanstha

RAM RATNA INTERNATIONAL SCHOOL University of Cambridge International Examinations, UK, IGCSE Curriculum

Keshav Srushti, Uttan-Gorai Road, Bhayandar (West), Dist. Thane - 401 106. Tel.: 022 - 2845 1612 / 13

GENERAL INFORMATION

Ram Ratna International School is the second project by Uttan Vividh Lakshyee Shikshan Sanstha. Ram Ratna International School is affiliated to the University of Cambridge International Examination. U.K. Admissions are open for the year 2013-14 only for the following grades: Pre-Primary : Nursery, Jr. KG & Sr. KG Primary : Grade I to V Middle School : Grade VI to VIII • • •

Admission Procedure: Age Eligibility:- Applicant student is expected to be born in the period shown against the respective grade for which admission is sought-

Nursery – 2 and ½ years and above as on 1st June 2013 Jr. KG. – 3 and ½ years and above as on 1st June 2013 Sr. KG – 4 and ½ years and above as on 1st June 2013 Grade 1 – 5 and ½ years and above as on 1st June 2013 (School will strictly abide by the age criteria of Nursery, Jr. KG., Sr. KG. & Grade 1)

Registration: • The registration forms are included in the Admission Information Kit available at the school office from 9.00 am to 1.00 pm (Monday to Friday) or can be downloaded from the school website and submitted online. Timings on Saturday: 10 am to 1 pm (except 4th Saturday) • A duly filled form obtained from the school website is to be submitted with the non-refundable, non-transferable registration fee of ` 500/- within 7 days from the date of issue of the form or the last date given. PLEASE NOTE THAT THE REGISTRATION AND PAYMENT OF THE PROCESSING FEE OF ` 500/- DOES NOT GUARANTEE ADMISSION TO RRIS.

Personal Interaction with the PRO and the Principal • Based on the personal interaction, entrance test (for grade II • For all matters related to admission, the decision of theAdmission Selection Committee will be final. • Parents of selected students will interact with the Admission Selection Committee.

onwards) and other criteria, the school reserves the right to admit any student who is found eligible for admission or refuse admission without assigning any reason.

A Global Educational Initiative of Uttan Vividh Lakshyee Shikshan Sanstha

RAM RATNA INTERNATIONAL SCHOOL University of Cambridge International Examinations, UK, IGCSE Curriculum

Keshav Srushti, Uttan-Gorai Road, Bhayandar (West), Dist. Thane - 401 106. Tel.: 022 - 2845 1612 / 13

ADMISSION PROCEDURE

PRE-SCHOOL (NURSERY) to Grade VIII for session 2013-2014 STEPS FOR ADMISSION:

a) Register online through our website - www.rrischool.org

b) Please submit ` 500 as registration fee online or through cheque, post or transfer online as instructed in the website.

c) Alternately, registration process can be completed at the school office. Meet our PRO or Admin. Officer.

d) Our executives will inform you about personal interaction with the principal for Nursery, Jr. KG, Sr. KG and grade I and written test for higher grades on an appointed day.

e) Results will be sent through SMS, E-mail and/or phone.

f) Make the payment of admission fee and 1st installment of tuition fee as per the details in the brochure. Pay online, by post or at the school counter within the deadline.

g) The school accepts payments through cheque /online.

h) Payment is to be made within 5 days of declaration of result.

i) Admission of a child is confirmed only after payment of the admission fee and 1st installment of tuition fee.

j) Fee once paid shall not be refunded. DOCUMENTS TO BE SUBMITTED AT THE TIME OF ADMISSION

a) ORIGINAL BIRTH CERTIFICATE ISSUED BY THE REGISTRAR / MUNICIPAL CORPORATION – (Pre-Primary and Grade I) .

b) IN CASE OF FOREIGN NATIONALS, PLEASE SUBMIT ATTESTED COPIES OF PASSPORT AND VISA.

c) IN CASE OF REAL SIBLING APPLICANTS, LATEST FEE BILL OF ADMISSION ORDER IS REQUIRED

d) THREE COLOURED PASSPORT SIZE PHOTOGRAPHS

e) TRANSFER/SCHOOL LEAVING CERTIFICATE (IF APPLICABLE) FROM THE PREVIOUS SCHOOL FOR

GRADES Sr. KG AND ABOVE

f) LAST SCHOOL’S REPORT CARD (IF APPLICABLE)

g) CASTE CERTIFICATE (IF APPLICABLE)

ADMISSION Students offered admission must complete the following formalities before joining or the admission will stand cancelled and the seat will be passed on to the next student in the ‘Waiting list.’ Parents should submit all the required attested documents, fill in the necessary forms and submit them online (preferably).

A. Pre-Primary and Grade I – Original Birth Certificate and attested photocopy to be sent online or by post. B. Grade II onwards – Birth Certificate, original School Leaving Certificate and the Report Card of the previous class

to be attested and sent online or by post. C. Three recent Passport size photos – not more than 6 months old, should either be scanned or sent online or by post. D. The required fee is to be paid within five days of confirmation of admission. E. Please note that Admission will be confirmed only after the realisation of fee.

Fee once paid will not be refunded. All the original or attested photocopied documents can be submitted at the school counter for the convenience of the parents. FEE DETAILS:

A term fee of Rs. 1000/-will be charged every 6 months and is applicable for all classes. New admission will be confirmed only after the deposit of Registration fee, Admission fee, and the first

installment of Tuition fee within the deadline. The fee structure does not include uniforms, books, and transport fees and meal fees. Late fee fine of Rs. 100/- per day will be applicable for late submission of fee beyond the deadline. Fee for the Ist

installment should reach within 5 working days of announcement of result of personal interview (for nursery to grade I) and admission test for grade II to grade VIII.

Admission to Grade 8 will be provided only to those students who have migrated from the school affiliated to CIE (Cambridge board curriculum).

Name of the child will be struck off from the school rolls I the fee is not paid within one month of the deadline. For re-admission, a fine of Rs. 5000/- will be applicable for all classes and cases. (For fee defaulters and other

disciplinary cases). Tuition fee should be paid every quarter failing which school will withdraw its facilities. The first installment of the fee should be paid along with the admission fee for new admissions. The first installment of the fee for old students should be paid by 10th of April. The second installment of the tuition fee is due by 10th July. The Third installment of the tuition fee is due by 10th October and the Fourth installment by 10th of January. The Term fee of 1000/- should be paid along with the 1st and 3rd installment of tuition fee. Software fee of Rs. 1000 p.a. is applicable for both new and old students. Whiteboard fee of Rs. 1000 per quarter is applicable for both new and old students.

TRANSPORTATION: Meals and bus facility is optional. The school provides bus facility on contract basis. School buses pick up the students from centralized points along the main roads. An attendant accompanies the children on all routes, as safety of your child is our priority. Transport service is provided depending on the number of requests for the service and the capacity of the bus. Admission to the school does not guarantee the transport facility.

MEALS: The school promotes only vegetarian food and we encourage our students to carry healthy food prepared at home. Meals facility is provided. Jain food is available for jain students.

1. RRIS is affiliated to the University of Cambridge, International Examinations, U.K.

2. The school follows Cambridge curriculum integrated with the best practices of the Indian

Education system.

3. The studies go beyond books. Practical work and projects are research oriented and based on

experimental studies.

4. There are no formal examinations up to grade IV. Mock checkpoint exams are conducted in grade

V and above. Grade VIII students can attempt checkpoint exams of CIE for which separate exam

fee needs to be paid to CIE, U.K (check cie website for further details). Grade X will take IGSCE

exams of CIE, for which too the exam fees should be paid separately. This fee will be borne by the

candidate.

5. If the information provided to the school is misleading or incorrect, the applicant will be

withdrawn from the process of school enrollment/ admission immediately without any

notification.

6. Please send us your e-mail/ letter / sms as soon as you have deposited fee online or by cheque in

the bank. Please ensure that you write the student’s name, class and phone numbers at the back

of the cheque.

7. Fee can be deposited in IDBI bank in the school account No. 536104000038067 directly. Please

check the details on the school website www.rrischool.org.

GENERAL INFORMATION REGARDING EXAMS

A Global Educational Initiative of Uttan Vividh Lakshyee Shikshan Sanstha

RAM RATNA INTERNATIONAL SCHOOL University of Cambridge International Examinations, UK, IGCSE Curriculum

Keshav Srushti, Uttan-Gorai Road, Bhayandar (West), Dist. Thane - 401 106. Tel.: 022 - 2845 1612 / 13

REGISTRATION FORM

To The Principal, Ram Ratna International School Bhayandar West, Thane - 401 106. Madam, I wish to seek admission of my son / daughter _________________________________________________________________ Date of Birth ___________________________ who is presently in class ___________________________________________ in _________________________________________________________________ (Name of the School) which is affiliated to STATE/ CBSE/ ICSE/ IGCSE Board/ Other (specify) Application for Admission to class _________________________________________for the session beginning from __________ Father's Name : ______________________________________________ Mobile No.: ______________________ Qualification : ______________________________________________ Occupation: ______________________ Mother's Name : ______________________________________________ Mobile No.: ______________________ Qualification : ______________________________________________ Occupation: ______________________ ResidentialAddress : __________________________________________________________________________________

__________________________________________________________________________________ Telephone No. (Off) : ______________________________________________ (Res) _____________________________ (Email ID) :______________________________________Language Spoken at Home: ______________________________ Name of Brother/ Sister ( applicable for blood relations only) studying in RRIS/ RRVM

1) ___________________________________ Grade: ____________________ Div: ________________ 2) ___________________________________ Grade: ____________________ Div: ________________ 3) ___________________________________ Grade: ____________________ Div: ________________

Date:___________________ Yours Faithfully

( ) Note: Submission of Registration form with processing fee `500/- does not guarantee admission at RRIS Incorrect / Incomplete admission forms will not be processed for admission. Original Birth Certificate / attested photocopy of Birth Certificate / Passport copy is to be submitted with registration form. Admission will be confirmed only after the registration fee, admission fee and the first installment of fee have been deposited within 5 working days of announcement of admission results.

For the year 201_ to 201_

A Global Educational Initiative of Uttan Vividh Lakshyee Shikshan Sanstha

RAM RATNA INTERNATIONAL SCHOOL University of Cambridge International Examinations, UK, IGCSE Curriculum

Keshav Srushti, Uttan-Gorai Road, Bhayandar (West), Dist. Thane - 401 106. Tel.: 022 - 2845 1612 / 13

ADMISSION FORM

To be filled by the Parent / Guardian of the Child (IN BLOCK LETTERS ONLY) Seeking admission for (Please Tick)

Nursery Sr. Kg. Grade II Grade IV Grade VI

Jr. Kg. Grade I Grade III Grade V Grade VII Grade VIII

Child’s Name in Full : ______________________ ______________________ _________________________ Last First Middle

Date of Birth: _______________ _______________ _______________ Sex: ____________________ Year Month Date Male/Female

Religion:________________________ Caste: _____________________ Sub Caste: ___________________________

Nationality: ________________________________ Place of Birth: _________________________ Residential Address: ____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

City: ________________ Pin: _____________ Tel: _____________ Cell Phone: __________________

Languages Spoken at Home :__________________________________________________________________ Name of the Current School :__________________________________________________________________ Address of the Current School :__________________________________________________________________

_________________________________________________________________

Board affiliation of the current school : SSC CBSE IB Other Please specify:_____________________________________

Category: Gen OBC SC ST Other

(The above information is required by the school as per S. S. Code of Maharashtra and will be kept confidential)

For any special learning needs, (This information will help us in assisting your child) please write your comments here (if any)

____________________________________________________________________________________________________

____________________________________________________________________________________________________

FAMILY INFORMATION

Father / Guardian Mother

Name: ______________________________ _________________________________

Occupation: ______________________________ _________________________________

Designation: ______________________________ _________________________________

Name of the Organisation: ______________________________ _________________________________ Address: ______________________________ _________________________________

______________________________ _________________________________

______________________________ ________________________________

Telephone (Res): ______________________________ _________________________________ Office: ______________________________ _________________________________

Mobile: ______________________________ _________________________________

Email ID: ______________________________ _________________________________ Family Details: Is the child staying: a) In a joint family YES NO b) With both parents YES NO

c) With grandparents/guardian YES NO d) With single parent YES NO

If yes, then who has the custody of the child? Father Mother

DECLARATION

• Each part of this application & information mentioned herein has been carefully read by me/us and is true and correct.

• I/We have no objection if our child’s photograph appears in any of the school brochures or any publication. • I/We undertake to abide by the rules and regulations of the institution. • The policy of the school regarding admission is binding on us. • I/We shall not be a party to any campaign / union against the school. • I/We shall not hold the school responsible for any mishap or accident to my child in unavoidable circumstances.

Father’s/Guardian’s Signature:___________________________________

Mother’s Signature: ___________________________________ Date:_____________ Signature of the Principal

A Global Educational Initiative of Uttan Vividh Lakshyee Shikshan Sanstha

RAM RATNA INTERNATIONAL SCHOOL University of Cambridge International Examinations, UK, IGCSE Curriculum

Keshav Srushti, Uttan-Gorai Road, Bhayandar (West), Dist. Thane - 401 106. Tel.: 022 - 2845 1612 / 13

RESOURCE FORM

Name of the Student: ___________________________________________________________________________________ Grade: __________________________ Division: __________________________ Parent's Name: ________________________________________________________________________________________ 1. In which areas are you willing to assist the school?

(Please tick the areas of help) Teaching Supervision Duty Arrangement of transport during Field Trips and Excursion Story Telling Library Reading ConductingArt & Craft and Pottery workshops GardeningActivities Organizing sports activities Arranging medical check -ups Training the students in Folk dance, Drama & Instrumental Music I T related activities As a Guest Speaker Hosting school students to a Picnic, Field Trip or visit to my workplace (Please specify number of students you can host)

2. Are you or your spouse into a profession (viz- Doctor, Scientist, Architect, Artist, Physical Fitness Instructor, Pilot, IT etc.) where you could share information about your profession with our kids? If yes, please specify. _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________

3. Please mention if you specialize in any other form of expertise that can contribute to the school . _______________________________________________________________________________________________ _______________________________________________________________________________________________

Date: __________________________ Signature of Parent/Guardian

____________________________

A Global Educational Initiative of Uttan Vividh Lakshyee Shikshan Sanstha

RAM RATNA INTERNATIONAL SCHOOL University of Cambridge International Examinations, UK, IGCSE Curriculum

Keshav Srushti, Uttan-Gorai Road, Bhayandar (West), Dist. Thane - 401 106. Tel.: 022 - 2845 1612 / 13

HEALTH INFORMATION FORM

Name of the Student : __________________________________________________________ Sex: Male/Female

Address : _________________________________________________________________________

_________________________________________________________________________

Date of Birth : Y________M_____D_____ (in words) _________________________________________

Blood Group : _________________________________________________________________________

Father's Name : _________________________________________________________________________

Mother's Name : _________________________________________________________________________

Father's Mobile Number : _________________________________________________________________________

Mother's Mobile Number : _________________________________________________________________________

In case of emergency, contact : Address: _________________________________________________________________

____________________________________________ Phone:_______________________

Friend's Or Relative’s Name : _________________________________ Address:________________________________

____________________________________________ Phone:_______________________

Family Physician's Name : _________________________________________________________________________

____________________________________________ Phone:_______________________

Hospital's Name : _________________________________ Address:________________________________

____________________________________________ Phone:_______________________

Allergies to any food or drugs, (if any) please specify: ________________________________________________________ In case of emergency, the school may call the family physician or any other physician to attend my child.

YES NO

I agree not to hold “RAM RATNA INTERNATIONAL SCHOOL” responsible for any illness, during classes or the school premises. I hereby verify that I have read, fully, understood and accepted the statement above. Date:__________________________ Name & Signature of Parents / Guardian

A Global Educational Initiative of Uttan Vividh Lakshyee Shikshan Sanstha

RAM RATNA INTERNATIONAL SCHOOL University of Cambridge International Examinations, UK, IGCSE Curriculum

Keshav Srushti, Uttan-Gorai Road, Bhayandar (West), Dist. Thane - 401 106. Tel.: 022 - 2845 1612 / 13

UNDERTAKING BY PARENTS/ GUARDIAN

Name of Student: _____________________________________________________________________ Grade: __________________________________ G.R. No.:____________________________________

1. I/We hereby undertake that I/We agree to abide by the rules & regulations of the School.

2. I/We will deposit the fee as per the schedule before the beginning of each term. If the school fee and penalty (if any) due are not paid by me within 30 days from the due date, I/We may be asked to withdraw my/our ward.

3. Request for leave for attending the marriage should be accompanied by an invitation card. No leave is granted to the student unless applied for directly to the principal.

4. I/We understand that my / our ward may be removed from the school for the following acts:

a) Using unfair means in any examination b) Consistent unsatisfactory progress c) Immorality d) Grave insubordination e) Stealing or extortion of money and /or items from other students / school f) Contempt of authority g) Breaking bounds h) Damaging school property i) Any word or action likely to undermine the reputation of the institution j) Bullying, assaulting, use of abusive language and ragging in any form k) Smoking, alcohol abuse and substance abuse l) Any other objectionable act

5. I/We understand that the school will do its best to provide normal medical aid, but will not be held responsible for any kind of

sickness and for all undisclosed diseases. In case of communicable/infectious disease, and for planned operations/procedures,

student will be sent home till he/she recovers.

Parent’s Signature Date:

 6.  If my/our ward leaves the school campus without permission, the school authorities may lodge an F. I. R. with the local 

police station and I/We will have no right to question and raise objections to this action. The school will not be responsible for any mishap in such circumstances. Fine for the same is ` 5,000, also applicable for any other serious default case as referred in point 4.   

7.  I/We shall ensure that my / our ward will report punctually to the school on the school opening days specified in the School Calendar failing which he exposes himself to disciplinary action including withdrawal.   

8.  I/We shall ensure that my / our ward does not carry any cash, electrical gadgets or any other costly items to the school.   9.  I/We & my / our family shall visit the school only on the days specified in the Visiting Schedule for the Parents/guardian.   10. I/We will not visit the campus without proper permission from the Principal.   11.  I/We understand that if arrangements for professional training/Cambridge examinations are required, I/We shall have to 

pay additional fees applicable.   

12. I/We assure that I/We will extend full co-operation to the School authorities in the interest of my / our ward. I/We have read the rules & regulations of Ram Ratna International School, Bhayander (West) and agree to abide by them. If, inspite of normal precautions taken by the school, any mishap, accident or injury takes place during the period of my/our ward's stay in the school or if and when he joins a tour, excursion, sports activities or camp, I/We will not hold the institute or any member of its staff wholly or partly responsible for it.    Date:_____________________  _____________________         ____________________________ 

 Signature of Father  Signature of Mother/Guardian   

(In case of Guardian: Relationship _____________________________ )   

Name(s) :  ______________________________________________________________ 

Phone No's 

Residence:  ______________________________________________________________ 

Office:  ______________________________________________________________ 

Mobile:  ______________________________________________________________ 

Fax:  ______________________________________________________________ 

e-mail address: ______________________________________________________________ 

 BRANCH'S COPY  SCHOOL'S COPY                      STUDENT'S COPY 

 To Be Sent to Bhayandar Branch on the Date of actual Credit of Funds By Collecting Branch. 

 DC No.  Date:  Unique ID No.  Date:  DC No.  Date:  To Be Entered By BANK  To Be Entered By BANK  To Be Entered By BANK 

         

 RAM RATNA INTERNATIONAL SCHOOL 

University of Cambridge International Examinations, UK, IGCSE Curriculum 

Keshav Srushti, Uttan-Gorai Road, Bhayandar (W), Dist. Thane - 401 106. Tel.: 022 - 2845 1612 / 13  

CHALLAN FOR PAYMENT OF SCHOOL FEES 

RAM RATNA INTERNATIONAL SCHOOL University of Cambridge International Examinations, 

UK, IGCSE Curriculum Keshav Srushti, Uttan-Gorai Road, Bhayandar (W), 

Dist. Thane - 401 106. Tel.: 022 - 2845 1612 / 13  

CHALLAN FOR PAYMENT OF SCHOOL FEES 

RAM RATNA INTERNATIONAL SCHOOL University of Cambridge International Examinations, 

UK, IGCSE Curriculum  Keshav Srushti, Uttan-Gorai Road, Bhayandar (W), 

Dist. Thane - 401 106. Tel.: 022 - 2845 1612 / 13  

CHALLAN FOR PAYMENT OF SCHOOL FEES  

Name of the Banker: IDBI Bank Bhayandar (E) Thane - 401101 

Branch Code: (536) Bhayandar Tel.: 022-28192275 Fax : 022-28188580 

Name of the Banker: IDBI Bank Bhayandar (E) Thane - 401101 

Branch Code: (536) Bhayandar Tel.: 022-28192275 Fax : 022-28188580 

Name of the Banker: IDBI Bank Bhayandar (E) Thane - 401101 

Branch Code: (536) Bhayandar Tel.: 022-28192275 Fax : 022-28188580 

  A ccount No 5 3 6 1 0 4 0 0 0 0 3 8 0 6 7  Account No 5 3 6 1 0 4 0 0 0 0 3 8 0 6 7          Account No 5 3 6 1 0 4 0 0 0 0 3 8 0 6 7  

Amount may be deposited in any branch of IDBI Bank Student Name  :_______________________________ 

G.R No.:_______________ STD:_________________ 

Address:____________________________________ ___________________________________________ ___________________________________________  Sr. Title  Amount  A  Registration Fee B  Security Deposit C  Admission Fee D  Tuition Fee E  Term Fee F   Bus Fee G  Meal Fee H  Late Fee / Fine I   Software Fee J 

Total 

RUPEES (in words): __________________________ 

____________________________________________    Signature of Bank Official  Depositors Signature Cheque No.  Date  * Name, GR. No., and STD to be Filled Compulsorily. 

Amount may be deposited in any branch of IDBI Bank Student Name  :_______________________________ 

G.R No.:_______________ STD:_________________ 

Address:____________________________________ ___________________________________________ ___________________________________________  Sr. Title                                    Amount  A  Registration Fee B  Security Deposit C  Admission Fee D  Tuition Fee E  Term Fee F   Bus Fee G  Meal Fee H  Late Fee / Fine I   Software Fee

J Total  

RUPEES (in words): __________________________ 

____________________________________________    Signature of Bank Official      Depositors Signature Cheque No.                   Date  * Name, GR. No., and STD to be Filled Compulsorily. 

Amount may be deposited in any branch of IDBI Bank Student Name  :_______________________________ 

G.R No.:_______________ STD:_________________ 

Address:____________________________________ ___________________________________________ ___________________________________________  Sr. Title                                    Amount  A  Registration Fee B  Security Deposit C  Admission Fee D  Tuition Fee E  Term Fee F   Bus Fee G  Meal Fee H  Late Fee / Fine I   Software Fee

J Total  

RUPEES (in words): __________________________ 

____________________________________________    Signature of Bank Official      Depositors Signature Cheque No.                   Date  * Name, GR. No., and STD to be Filled Compulsorily. 

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