Common Application Form (Waiting Round) 24D294015

For Admission into Degree Course (2024-25)

Higher Education Department, Government of Odisha +3
(PHASE-I)
Applicant Copy
Friday, Jul 26, 2024 10:10:33 AM

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 104FA202

2 Applicant's Name PRASANTINI SAHOO

3 Father's Name PRASANTA KUMAR SAHOO

4 Mother's Name SANGITA SAHOO

Blood Group Gender Religion Date of Birth

FEMALE HINDUSIM 17 Mar 2004

Nationality Mother Tongue Aadhaar No. Parent Mobile No.

INDIAN ODIA ********2646 6371471542

5 Personal Details
Child without biological or adoptive parents No Orphan No

Staying at Child Care Institutions No Green Passage No

Apaar ID

6. Permanent Address

a. State ODISHA b. District KALAHANDI c. Block / ULB LANJIGARH

d. Address AT/PO-BISWANATHPUR e. PIN Code 766020

f. Whatsapp No. 9937574010 g. Mobile No. 9937574010

h. e-Mail [email protected]

7. Reservation Details

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

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?
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
600 399 77 48 0

c. Have you studied Odia at HSC/+2 Level or No

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 HOME Actual Income of the Parents

a. Father's Occupation BUSINESS b. c. 10000
Occupation MAKER (Together)in Rs.

d. Annual Income of the Parents (Together)in Rs. 0 - 1,50,000

e. Dose your parents are paying Income Tax? No

11 Bank Information

a. Account Number 39626223587 b. IFSC Number SBIN0006179

d. Bank Name STATE BANK OF INDIA e. Branch Name BISWANATHPUR

f. Name of Account Holder PRASANTINI SAHOO

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 Future Career Option

d. No e. Farmer
under NASSCOM/Infosys Springboard? Desired by Applicant

12 Record of educational institution last attended

Name of the GOVERNMENT HIGHER SECONDARY SCHOOL, Location of the

a. b. BHAWANIPATNA
School/College BHAWANIPATNA School/College

c. District KALAHANDI d. Year of Joining 2022

e. Year of Leaving 2024

13 Option(s)/Choice(s) Details

Option College Stream Preference Subject Hostel Admission

Option Fee

2nd Kalahandi University, Kalahandi (Erstwhile Government Autonomous College, Arts HONOURS POLITICAL YES 4277.00
Bhawanipatna) SCIENCE

3rd Kalahandi University, Kalahandi (Erstwhile Government Autonomous College, Arts HONOURS ECONOMICS YES 4277.00
Bhawanipatna)

4th Rama Devi Women's University , Bhubaneswar (Erstwhile RD Autonomus Arts HONOURS POLITICAL YES 3540.00
College) 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
UPI SUCCESS 275.00 2934223539918 12-06-2024

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.