Common Application Form 24H4572019

Admission to Higher Secondary School

Academic Session (2024-25)
Department of School & Mass Education, Government of Odisha XI
Phase-I(Spot)

Monday, Aug 12, 2024 01:00:34 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 174FA0159

2. Applicant's Name SIBANI BHATRA

3. Father's Name DAMODAR BHATRA

4. Mother's Name TULABATI BHATRA

5. Personal Details Blood Group Gender Religion Date of Birth
FEMALE HINDUISM 09-Jul-2008
Nationality Mother Tongue Aadhaar No. Guardian Mobile No. Orphan
INDIAN ODIA ********6218 8480247024 No

6. Address for Correspondence

a. State ODISHA b. District KORAPUT c. Block / ULB BORIGUMMA

d. Address AT-DABAGAM PO-KOSAGUDA PS-KOTPAD e. PIN Code 764056

f. Telephone No. g. Mobile No. 9337052858 h. Whatsapp No. 9337052858 i. e-Mail [email protected]

J. NMMS Awardee No

K. NEET/JEE Details

NEET JEE Other Competitive Exams None Of These

No No No Yes

7. Reservation Details
a. Schedule Tribe Yes Schedule Caste No Other Backward Class No 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 10th Board Maximum Mark Total Mark Secured English/SL Mathematics Science Social Science Grade
Examination
600 240 44 36 33 42 D

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 84054813655 b. IFSC Number SBIN0RRUKGB

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

e. Branch Name UTKAL GRAMYA BANK RRB

12. Record of educational institution last attended

a. Name of the School PANCHAYAT HIGH SCHOOL, SASAHANDI b. Location of the School SASAHANDI

c. District KORAPUT d. Year of Joining 2022

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 Nabarangpur Higher Arts MIL Odia History, Optional Odia, Political Science Information Technology No
Secondary School,
Nawarangpur

2nd Nabarangpur Higher Science MIL Odia Physics, Chemistry, Information Technology Plumber No
Secondary School,
Nawarangpur

3rd Nabarangpur Higher Commerce MIL Odia Accountancy, Business Mathematics and Statistics, Business Studies and Management Information Technology No
Secondary School,
Nawarangpur

4th Vikram Deb Higher Secondary Arts MIL Odia History, Optional Odia, Sociology Tourisim and Hospitality No
School, Jeypore

5th Government Women's Higher Arts MIL Odia Education, History, Political Science Home Science No
Secondary School, Jeypore

Payment Details

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

ONLINE SUCCESS 100.00 4046728533946 05/07/2024

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

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).

3 Scheduled Tribe (ST) / Scheduled Caste (SC) / Other Backward Classes (OBC) certificates from revenue officer not below rank of Tahasildar / Additional Tahasildar.