6/10/24, 8:01 PM SAMS :: CAF PRINT

Common Application Form 24D234551

For Admission into Degree Course (2024-25)
Higher Education Department, Government of Odisha +3
Applicant Copy (PHASE-I)

Monday, Jun 10, 2024 08:01:48 PM

Your CAF has been Validated. It will be checked at the time of admission.

1 +2 Council Details Name of the Examination Board

(As in admit Card) COUNCIL OF HIGHER SECONDARY EDUCATION, ODISHA

Year of Passing Exam Type Roll Number

2024 Annual 106ND008

2 Applicant's Name SULAGNA SUBHADARSINI

3 Father's Name DR. KISHORE KUMAR BISWAL

4 Mother's Name DR. SANJUKTA PADHI

Blood Group Gender Religion Date of Birth

AB+ FEMALE HINDUSIM 11 Aug 2006
Nationality Mother Tongue Aadhaar No. Parent Mobile No.
INDIAN ODIA ********4008 7978706852
5 Personal Details
Child without biological or adoptive parents No Orphan No

Staying at Child Care Institutions No Green Passage No

Apaar ID 902003176805

6. Permanent Address

a. State ODISHA b. District SAMBALPUR c. Block / ULB SAMBALPUR (MC)

d. Address LANE-4, FATAK-KHETRAJPUR ROAD BACK SIDE OF GM UNIVERSITY e. PIN Code 768004

f. Whatsapp No. 9178022116 g. Mobile No. 9178022116

h. e-Mail [email protected]

7. Reservation Details

a. Schedule Tribe No Schedule Caste No Other Backward Class No Socially and Educationally Backward Class No General Yes

b. Persons with Disabilities No

c. Ex-Service Man No Serving Defence Personnel No Children of Martyrs No

Do you have odisha domicile(Resident)

Yes
Certificate?

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8. Weightage Details

a. NCC b. NSS Camp

NCC-B No NCC No International No National No State Level(Issued by No Best NSS No

Certificate (CAMP/COURSE/ACTIVITIES) Level Level State NSS Cell) Volunteer Award

c. Rover & Ranger d. Sports & Games

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

9. Details of Mark Secured in +2 or equivalent Examination

a. Stream Arts

b. Mark secured in each subject in +2 or Maximum Mark Total Mark Secured English MIL Mathematics
equivalent Examination
600 492 88 84 0

c. Have you studied Odia at HSC/+2 Level or Yes

Higher (or Passed Odia as a special Exam
from BSE Odisha in 10th Standard)?

d. Have you passed +2 or equivalent Exam No

Compartmentally / Instant?

10. Income Details of Parents

Mother's Actual Income of the Parents

a. Father's Occupation GOVT.SERVICE b. GOVT.SERVICE c. 1000000
Occupation (Together)in Rs.

d. Annual Income of the Parents (Together)in Rs. Above 8,00,000

e. Dose your parents are paying Income Tax? Yes

11 Bank Information

a. Account Number 31533818135 b. IFSC Number SBIN0001820

d. Bank Name STATE BANK OF INDIA e. Branch Name JAJPUR ROAD

f. Name of Account Holder sanjukta padhi

Other Information

a. Special Category None of these

Does parent hold a

b. Does parents have a KALIA beneficiary? No c. No
Labour card?
Are you willing to participate in skilling courses under Future Career Option
d. Yes e. Administrative Officer
NASSCOM/Infosys Springboard? Desired by Applicant

12 Record of educational institution last attended

Name of the GANGADHAR MEHER HIGHER SECONDARY Location of the

a. b. FATAK, SAMBALPUR
School/College SCHOOL, SAMBALPUR School/College

c. District SAMBALPUR d. Year of Joining 2022

e. Year of Leaving 2024

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13 Option(s)/Choice(s) Details

Option College Stream Preference Subject Hostel Admission

Option Fee

1st Ravenshaw University,Cuttack Arts HONOURS POLITICAL YES 1750.00

SCIENCE

2nd Gangadhar Meher University, Sambalpur Arts HONOURS POLITICAL NO 4660.00

SCIENCE

3rd Buxi Jagabandhu Bidyadhar (Autonomous) College, Bhubaneswar Arts HONOURS POLITICAL YES 2952.00
SCIENCE

4th Rama Devi Women's University , Bhubaneswar (Erstwhile RD Arts HONOURS POLITICAL YES 3540.00
Autonomus College) SCIENCE

5th Shailabala Women's (Autonomous) College, Cuttack Arts HONOURS POLITICAL YES 2268.00
SCIENCE

Note: The admission fee may vary at the time of admission.

Payment Details
Mode of Payment Payment Status Amount Paid Transaction No. Transaction Date
NB SUCCESS 275.00 7595481150836 07-06-2024

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).

2 Higher Secondary (+2) Mark Sheets-cum-Provisional Certificate (or equivalent Board). If an applicant has not received the mark sheet from 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.

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