St.
Xavier School
Affiliated to C.B.S.E, New Delhi
Affilia on No 2132352/ School Code 70155
Jiyanpur, Azamgarh (U.P) Pin Code - 276140
SCHOOL LEAVING CERTIFICATE
Book No................... Sl. No................... Admission No...................
1. Name of Pupil...................................................................................................................................................
2. Father's/Guardian Name...................................................................................................................................
3. Mother’s Name................................................................................................................................................
4. Na onality........................................................................................................................................................
5. Whether the candidate belongs to Schedule Cast or Schedule Tribe..................................................................
6. Date of first admission in the school with class..................................................................................................
7. Date of birth (in Chris an Era) according to Admission Register (in figures)....................................................... (in
words)..........................................................................................................................................................
8. Class in which the pupil last studied..................................................................................................................
9. School/Board Annual examina on last taken with result..................................................................................
10. Whether failed, if so once/twice in the same class..........................................................................................
11. Subject studied: 1........................2..........................3............................4...........................5...........................
12. Whether qualified for promo on to the higher class............... If so, to which class (in figure).........................
13. Month upto which the (pupil has paid) school dues/paid................................................................................
14. Any fee concession availed of: If so, the nature of such concession.................................................................
15. Total No. of working days...……………….............................................................................................................
16. Total No. of working day present.....................................................................................................................
17. Whether NCC Cadet/Boy Scout/Girl Guide (Details may be given.)...................................................……………..
18. Games played or co-curricular ac vi es in which the pupil usually took part
(Men on achievement level therein)
19. General conduct..............................................................................................................................................
20. Date of applica on for cer ficate....................................................................................................................
21. Date of issue cer ficate...................................................................................................................................
22. Reasons for leaving the school........................................................................................................................
23. Any other remarks...........................................................................................................................................
......................................... ......................................... .........................................
Signature of Checked by Principal's Sign.
Class Teacher (Full name & designa on) Seal With Full Address
