Common Application Form

for Admission to Junior Colleges (2014-15)

Department of Higher Education, Government of Odisha
Saturday, Jun 7, 2014 10:15:22 AM
14J0543578
+2
Money Receipt-cum-Index Number /
Fees
(Rs.)
200.00 Date of Submission at College

Signature of the Receiving
Official
1
10th Board Details
(As in admit Card)
Name of the
Examination Board
Year of
Passing
Exam Type Roll Number
BSE, ODISHA 2014 Annual 018CC043
2 Applicant's Name
SIDHESWAR PRADHAN
3 Father's Name
FAKIRA CHARAN PRADHAN
4 Mother's Name
SABITA RANI PRADHAN
5 Personal Details
Blood Group Sex Religion Date of Birth
O+

MALE

HINDU

14-Nov-1998
Affi x your sel f attested (on
the front) recent col or
passport si ze photographs
here
6. Address for Correspondence
a. State
ODISHA
b. District
KEONJHAR
c. Block / ULB
JHUMPURA
d. Address AT/PO- BALIBANDH e. PIN Code
758031
f.
Telephone
No.
g.
Mobile
No.
8908078722
h. e-Mail
amreshpradhan@hotmail.com
7. Reservation Details
a. Schedule Tribe (ST)
No

Schedule Caste
(SC)
No
Others
Yes

b.
Physically/Orthopedically
Handicapped (PH/OH)
No

Ex-Service Man
(ESM)
No
Serving Defence
Personnel (SDP)
No
Children of
Martyrs (CoM)
No
c. Are you an Outside State Applicant (OSA)?
No

d.
Are you an Oriya Living in Neighbouring State
(OLNS)applicant ?
No
8. Weightage Details
a. NCC
NCC (A) No
NCC
(C)
No

b. Scout & Guide
Rajya
Puraskar(RP)
No
President
Recognition(PR)
No

c. Sports
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
Examination
Maximum
Mark
Total Mark
Secured
English Mathematics Science
Social
Science
Grade
600 409 60 60 58 63 B2
Have you secured above mark
in your Annual HSE(O)
Yes
examination ?
b.
Have you passed 10th Board
Exam Compartmentally ?
No

10 Option(s)/Choice(s) Details
Option College Name Stream Compulsory Electives
4th Electives in
order of preference
Hostel
Option
FIRST
Chandra Sekhar (Junior) College,
Champua
Science MIL Oriya Physics,Chemistry,Biology Mathematics,Geology Yes
SECOND Rimuli (Junior) College, Rimuli Science MIL Oriya Physics,Chemistry,Biology Mathematics No
THIRD
Jhumpura Panchayat Samiti (Junior)
College, Jhumpura
Science MIL Oriya Physics,Chemistry,Biology Mathematics Yes
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 (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 (College Copy).
2 HSC Mark Sheets-cum-Provisional Certificate (or equivalent Board).
14J0543578
Common Application Form
for Admission to Junior Colleges
Department of Higher Education, Government of Odisha
Applicant Copy
Saturday, Jun 7, 2014 10:15:22 AM
14J0543578
+2
For Official use only
Money Receipt-cum-Index Number /
Fees
(Rs.)
200.00 Date of Submission at College

Signature of the Receiving Of f icial
1
10th Board Details
(As in admit Card)
BSE, ODISHA 2014 Annual 018CC043
2 Applicant's Name
SIDHESWAR PRADHAN
3 Personal Details
O+

MALE

HINDU

14-Nov-1998
4. Reservation Details
a. ST
No
SC
No
Others
Yes
(PH/OH)
No
ESM
No
SDP
No
CoM
No

b. Are you an Outside State Applicant (OSA) ?
No
c.
Are you an Oriya Living in Neighbouring State (OLNS)
applicant ?
No
5. Weightage Details
a. NCC
NCC
(A)
No
NCC
(C)
No

b. Scout & Guide
Rajya
Puraskar(RP)
No
President
Recognition(PR)
No

c. Sports
State No National No International No
6. Details of Mark/Grade Secured in 10th Board Examination
a.
Mark/Grade secured in each
subject in 10th Board
Examination
Maximum Mark Total Mark Secured English Mathematics Science Social Science Grade
600 409 60 60 58 63 B2
Have you secured above mark
in your Annual HSE(O)
examination ?
Yes
b.
Have you passed 10th Board
Exam Compartmentally ?
No

7. Option(s)/Choice(s) Details
Option College Name StreamCompulsory Electives
4th Electives inorder
of preference
Hostel
Option
FIRST
Chandra Sekhar (Junior) College,
Champua
ScienceMIL Oriya Physics,Chemistry,BiologyMathematics,GeologyYes
SECONDRimuli (Junior) College, Rimuli ScienceMIL Oriya Physics,Chemistry,BiologyMathematics No
THIRD
Jhumpura Panchayat Samiti (Junior)
College, Jhumpura
ScienceMIL Oriya Physics,Chemistry,BiologyMathematics Yes