6/26/2019 CAF-2019

Common Application Form 19D091832

for Admission to Degree Colleges (2019-20)
Department of Higher Education, Government of Odisha
College Copy +3
Wednesday, Jun 26, 2019 10:47:43 PM

For Official use only

Money Receipt-cum-Index Number College Code / Index No.

Fees (Rs.) 275.00 Date of Submission at College Signature of the

Receiving Official

Name of the Examination Year of

Exam Type Roll Number
+2 Council Details Board Passing
1
(as in admit Card)
CBSE, NEW DELHI 2019 Annual 6605968

2 Applicant's Name SHARMISTHA SAMANTARAY

3 Father's Name KIRANCHAND SAMANTARAY

4 Mother's Name MOUSUMI SAMANTARAY

Blood Group Gender Religion Date of Birth Affix your self attested
(on the front) recent color
AB+ FEMALE HINDU 14 Feb 2002 passport size
5 Personal Details photographs here
Nationality Mother Tongue Aadhaar No.

INDIAN ODIA 831250933066

6. Permanent Address

a. State ODISHA b. District DHENKANAL c. Block / ULB DHENKANAL (MPL)

C/O SUSHANTA KUMAR PANY B-59 BHAGIRATHI VIHAR,

d. Address e. PIN Code 759001
NUAPOKHARI, GUDIANALI, DHENKANAL

Telephone Mobile
f. g. 9437116939 h. e-Mail [email protected]
No. No.

7. Reservation Details

Schedule Caste
a. Schedule Tribe (ST) No No OBC No SEBC No General Yes
(SC)

Physically/Orthopedically Ex-Service Man Serving Defence Children of Martyrs

b. No No No No
Handicapped (PH/OH) (ESM) Personnel (SDP) (CoM)

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6/26/2019 CAF-2019

8. Weightage Details

a. NCC b. NSS Camp

NCC NCC University Level No State Level No National Level No International Level No
No No
B (CAMP/COURSE)

c. Rover & Ranger d. Sports & Games

Rajya Puraskar(RP) No President Recognition(PR) No State No National No International No

9. Details of Mark Secured in +2 Council Examination

a. Stream Science

Maximum Mark Total Mark Secured MIL English Chemistry Mathematics Biology
Mark secured in each subject in
b.
+2 Council Examination 500 367 78 63 0 70

Have you passed +2 Council

c. Exam Compartmentally / Instant No
?

10. Income Details of Parents

a. Father's Occupation GOVT.SERVICE b. Mother's Occupation HOME MAKER

c. Annual Income of the Parents (Together)in Rs. Above 6,00,000

11 Bank Information

a. Account Number 38550896671 b. IFSC Number SBIN0000039

c. MICR Code 766002002 d. Bank Name STATE BANK OF INDIA

e. Branch Name BHAWANIPATNA

12 Record of educational institution last attended

a. Name of the School KENDRIYA VIDYALAYA b. Location of the School BHAWANIPATNA

c. District KALAHANDI d. Year of Joining 2007

e. Year of Leaving 2019

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13 Option(s)/Choice(s) Details

Option College Stream Preference Subject Hostel Option

FIRST Basic Science & Humanities (Degree) College, Bhubaneswar Biological Science HONOURS ZOOLOGY,, YES

SECOND Buxi Jagabandhu Bidyadhar (Autonomous) College, Bhubaneswar Biological Science HONOURS ZOOLOGY,, YES

THIRD Government (Autonomous) College, Bhawanipatna Biological Science HONOURS ZOOLOGY,, NO

FOURTH Basic Science & Humanities (Degree) College, Bhubaneswar Biological Science HONOURS BOTANY,, YES

FIFTH Buxi Jagabandhu Bidyadhar (Autonomous) College, Bhubaneswar Biological Science HONOURS BOTANY,, YES

SIXTH Dhenkanal (Autonomous) College, Dhenkanal Biological Science HONOURS ZOOLOGY,, YES

SEVENTH Government (Autonomous) College, Bhawanipatna Biological Science HONOURS BOTANY,, NO

Payment Details

Mode of Payment Payment Status Amount Paid Transaction No.

ONLINE SUCCESS 275.00 PG9117722445274

UNDERTAKING

I do hereby agree to abide by the rules of the College/Hostel. I undertake that should any indiscipline and disobedience instance of the rules laid
down by the Government or any authority empowered by them in this regard or should conduct in the college is found not satisfactory, my name will
automatically be removed from the college. I undertake that information furnished by me in this application is true and correct and i undertake that
any wrong information furnished be me, detected afterwards will be treated as cognizable offence.

I further undertake that i will not involve in any ragging activities in the college and hostel premises. I understand that criminal case will be filed
against me if indulge in ragging

I hereby fully endorse the undertaking made by our

child / ward Submitted by me

Signature or thumb impression of parents/ guardian Full Signature of Applicant

Date Place Date Place

Enclosures (The following documents would enclosed along with the CAF)

Sl.# Documents

1 One (1) self signed (on the front side) recent color passport size photograph to be affixed in the CAF (College Copy).

Higher Secondary (+2) Mark Sheets-cum-Provisional Certificate (or equivalent Board). If an applicant has not received the mark sheet from
2
the board in-time, then the downloaded mark sheet from Internet, duly endorsed by the leaving School/College Principal will be admissible.

3 Self signed (on the front side) color passport size photograph (1 Copy) to be affixed in the CAF.

19D091832

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6/26/2019 CAF-2019

19D091832
Common Application Form
for Admission to Degree Colleges (2019-20)
Department of Higher Education, Government of Odisha
Applicant Copy +3
Wednesday, Jun 26, 2019 10:47:43 PM

For Official use only

Money Receipt-cum-Index
College Code / Index No.
Number
Signature of the Receiving
Fees (Rs.) 275.00 Date of Submission at College Official

+2 Council Details
1 CBSE, NEW DELHI 2019 Annual 6605968
(as in admit Card)

2 Applicant's Name SHARMISTHA SAMANTARAY

3 Personal Details AB+ FEMALE HINDU 14 Feb 2002 831250933066

4. Reservation Details

a. ST No SC No OBC No SEBC No General Yes PH/OH No ESM No SDP No CoM No

5. Weightage Details

a. NCC b. NSS Camp

NCC NCC University Level No State Level No National Level No International Level No
No No
B (CAMP/COURSE)

c. Rover & Ranger d. Sports & Games

Rajya Puraskar(RP) No President Recognition(PR) No State No National No International No

6. Details of Mark Secured in +2 Council Examination

a. Stream Science

Maximum Mark Total Mark Secured MIL English Chemistry Mathematics Biology
Mark secured in each subject in
b.
+2 Council Examination 500 367 78 63 0 70

Have you passed +2 Council

c. Exam Compartmentally / Instant No
?

https://online.samsodisha.gov.in/ONLINE_CAF_Degree/CAF.aspx?enc=Zh0FA9fEZ5pQR90vKS5vNW0S2S/LiFHTAUD2fIyfpQyLZ3LTuFXExC9r6… 4/5
6/26/2019 CAF-2019

7. Option(s)/Choice(s) Details

Option College Stream Preference Subject Hostel Option

FIRST Basic Science & Humanities (Degree) College, Bhubaneswar Biological Science HONOURS ZOOLOGY,, YES

SECOND Buxi Jagabandhu Bidyadhar (Autonomous) College, Bhubaneswar Biological Science HONOURS ZOOLOGY,, YES

THIRD Government (Autonomous) College, Bhawanipatna Biological Science HONOURS ZOOLOGY,, NO

FOURTH Basic Science & Humanities (Degree) College, Bhubaneswar Biological Science HONOURS BOTANY,, YES

FIFTH Buxi Jagabandhu Bidyadhar (Autonomous) College, Bhubaneswar Biological Science HONOURS BOTANY,, YES

SIXTH Dhenkanal (Autonomous) College, Dhenkanal Biological Science HONOURS ZOOLOGY,, YES

SEVENTH Government (Autonomous) College, Bhawanipatna Biological Science HONOURS BOTANY,, NO

Payment Details

Mode of Payment Payment Status Amount Paid Transaction No.

ONLINE SUCCESS 275.00 PG9117722445274

https://online.samsodisha.gov.in/ONLINE_CAF_Degree/CAF.aspx?enc=Zh0FA9fEZ5pQR90vKS5vNW0S2S/LiFHTAUD2fIyfpQyLZ3LTuFXExC9r6… 5/5