6/12/24, 11:34 PM SAMS :: Student Academic Management System

Common Application Form 24H2516453

Admission to Higher Secondary School
Academic Session (2024-25)
Department of School & Mass Education, Government of Odisha
XI
Phase - I

Wednesday, Jun 12, 2024 11:34:48 PM

Note:-This CAF Applicant Copy is required to submit at the time of admission.

1. 10th Board Details Name of the Examination Board Year of Passing Exam Type Roll Number
(As in Admit Card) BSE, ODISHA 2024 Annual 256ek0296

2. Applicant's Name PRATYUSH PUJARI

3. Father's Name NAYAN KUMAR PUJARI

4. Mother's Name SARITA PUJARI

5. Personal Details Blood Group Gender Religion Date of Birth
A+ MALE HINDUISM 04-Mar-2009
Nationality Mother Tongue Aadhaar No. Guardian Mobile No. Orphan
INDIAN ODIA ********0149 9937512497 No

6. Address for Correspondence

a. State ODISHA b. District SUNDARGARH c. Block / ULB SUBDEGA

C/O- NAYAN KUMAR PUJARI, VILL- JAGANNATH POSH, PO-

d. Address e. PIN Code 770002
PANCHMAHALA, PS- SADAR, SUNDARGARH

Whatsapp
f. Telephone No. g. Mobile No. 9937512497 h. 9937512497 i. e-Mail [email protected]
No.

J. NMMS Awardee No

K. NEET/JEE Details

NEET JEE Other Competitive Exams None Of These

No No Yes No

7. Reservation Details
a. Schedule Tribe No Schedule Caste No Other Backward Class No Socially and Educationally Backward Classes No General Yes

b. Persons with Disabilities No Ex-Service Man No Serving Defence Personnel No Children of Martyrs No

8. Weightage Details

NCC Scout & Guide Sports

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

9. Details of Mark/Grade Secured in 10th Board Examination

a. Mark/Grade secured in each subject in Maximum Mark Total Mark Secured English/SL Mathematics Science Social Science Grade
10th Board Examination
600 439 81 60 53 78 B1

b. Have you passed 10th Board Exam No

Compartmentally ?

https://online.samsodisha.gov.in/ONLINE_CAF/CAFJrV2.aspx 1/3
6/12/24, 11:34 PM SAMS :: Student Academic Management System

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. 2,50,001 - 6,00,000

11. Bank Information

a. Account Number 717802120000694 b. IFSC Number UBIN0571784

c. MICR Code 770026002 d. Bank Name UNION BANK OF INDIA

e. Branch Name SUNDARGARH

12. Record of educational institution last attended

a. Name of the School SARASWATI VIDYAMANDIR, DENGIVADI b. Location of the School SUNDARGARH TOWN

c. District SUNDARGARH d. Year of Joining 2014

e. Year of Leaving 2024

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

Option HSS Name Stream Compulsory Electives 4th Electives inorder of preference Hostel
Option

1st Government Higher Commerce MIL Alternative Accountancy, Business Mathematics Banking Insurance and Cost No
Secondary School, English and Statistics, Business Studies and Accounting,Salesmanship and Business
Sundargarh Management Economics,Banking

2nd Laxmi Narayan Commerce MIL Alternative Accountancy, Business Mathematics Banking Insurance and Cost Yes
Higher Secondary English and Statistics, Business Studies and Accounting,Salesmanship and Business
School, Jharsuguda Management Economics,Information Technology

3rd Municipal Higher Commerce MIL Alternative Accountancy, Business Mathematics Banking Insurance and Cost No
Secondary School, English and Statistics, Business Studies and Accounting,Salesmanship and Business
Rourkela Management Economics,Information Technology

4th Dalmia Higher Commerce MIL Alternative Accountancy, Business Mathematics Mathematics,Banking Insurance and Cost Yes
Secondary School, English and Statistics, Business Studies and Accounting,Salesmanship and Business
Jharbeda Management Economics

5th Belpahar Higher Commerce MIL Alternative Accountancy, Business Mathematics Banking Insurance and Cost No
Secondary School, English and Statistics, Business Studies and Accounting,Salesmanship and Business
Belpahar Management Economics,Information Technology

Payment Details

Mode of Payment Payment Status Amount Paid Transaction No. Transaction Date

ONLINE SUCCESS 200.00 ZIC52066909560 12/06/2024

UNDERTAKING
I do hereby agree to abide by the rules of the HSS/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 HSS is found not satisfactory, my name will automatically be
removed from the HSS. 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 HSS 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

https://online.samsodisha.gov.in/ONLINE_CAF/CAFJrV2.aspx 2/3
6/12/24, 11:34 PM SAMS :: Student Academic Management System
Enclosures (Certified True Copy of 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 (HSS Copy).

2 True Copy of HSC Mark Sheets-cum-Provisional Certificate (or equivalent Board).

https://online.samsodisha.gov.in/ONLINE_CAF/CAFJrV2.aspx 3/3