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    SAMS :: Student Academic Management System

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    igiabi1
    Student Academic Management System

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    © All Rights Reserved
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    SAMS :: Student Academic Management System

    Uploaded by

    igiabi1
    21 views3 pages
    Student Academic Management System

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    © © All Rights Reserved

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    PDF, TXT or read online from Scribd

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    Student Academic Management System

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    21 views3 pages

    SAMS :: Student Academic Management System

    Uploaded by

    igiabi1
    Student Academic Management System

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 3

    Common Application Form 22H5259832

    Admission to Higher Secondary School


    Academic Session (2022-23)
    Department of School & Mass Education, Government of Odisha XI
    Phase - II
    Thursday, Sep 22, 2022 09:08:09 AM
    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 2022 Annual 146CD0140

    2. Applicant's Name JAREEN PREETY

    3. Father's Name PABITRA MOHAN MOHANTA

    4. Mother's Name PADMABATI MOHANTA


    5. Personal Details Blood Group Sex Religion Date of Birth
    FEMALE HINDUISM 10-Jun-2007
    Nationality Mother Tongue Aadhaar No. Guardian Mobile No. Orphan
    INDIAN ODIA 299104642903 7894366240 No

    6. Address for Correspondence

    a. State ODISHA b. District MAYURBHANJ c. Block / ULB JASHIPUR

    d. Address AT/PO-MAUDI PS-JASHIPUR e. PIN Code 757034© 2022-2023


    SAMS Application
    Whatsapp
    f. Telephone No. g. Mobile No. 9437831786 h. 9437831786 i. e-Mail [email protected]
    No.

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

    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
    600 414 75 55 69 60 B2

    b. Have you passed 10th Board Exam No


    Compartmentally ?

    10. Income Details of Parents

    a. Father's Occupation CULTIVATION b. Mother's Occupation HOME MAKER

    c. Annual Income of the Parents (Together)in Rs. 0-1,00,000

    11. Bank Information


    a. Account Number 38676847593 b. IFSC Number SBIN0012049

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

    e. Branch Name JASHIPUR

    12. Record of educational institution last attended

    a. Name of the School JASHIPUR GIRLS HIGH SCHOOL, JASHIPUR b. Location of the School JASHIPUR

    c. District MAYURBHANJ d. Year of Joining 2018

    e. Year of Leaving 2022 f. Student Unique ID

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

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

    1st Jashipur Higher Secondary School, Jashipur Science MIL Odia Physics,Chemistry,Biology Mathematics No

    2nd Chaitanya Prasad Higher Secondary School, Bhanjakia Science MIL Odia Physics,Chemistry,Biology Mathematics No

    3rd Angarpada Panchayat Higher Secondary School, Science MIL Odia Physics,Chemistry,Biology Mathematics No
    Raruan

    4th Panchapir Womens Higher Secondary School, Karanjia Science MIL Odia Physics,Chemistry,Biology Mathematics Yes

    5th Biju Patnaik Higher Secondary School, Singda Science MIL Odia Physics,Chemistry,Biology Mathematics No

    6th Karanjia Higher Secondary School, Karanjia Science MIL Odia Physics,Chemistry,Biology Mathematics Yes

    7th Maa Kitchakeswari Higher Secondary School, Khiching Science MIL Odia Physics,Chemistry,Biology Mathematics No

    8th Sukruli Higher Secondary School, Sukruli Science MIL Odia Physics,Chemistry,Biology Mathematics No

    9th Swampatna Anchalika Higher Secondary School, Science MIL Odia Physics,Chemistry,Biology Mathematics No
    Swampatna

    10th Raghunath Higher Secondary School, Kadadiha Science MIL Odia Physics,Chemistry,Biology Mathematics No

    Payment Details

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

    ONLINE SUCCESS 200.00 0611648766515 16/09/2022

    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

    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).

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