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5/25/2017 CAF2017

CommonApplicationForm 17J1882274
forAdmissiontoJuniorColleges(201718)
DepartmentofSchool&MassEducation,GovernmentofOdisha

+2
Thursday,May25,201710:18:26AM

MoneyReceiptcumIndexNumber /
SignatureoftheReceiving
Fees(Rs.) 200.00 DateofSubmissionatCollege Official

NameoftheExamination Yearof
10thBoardDetails ExamType RollNumber
1 Board Passing
(AsinadmitCard)
BSE,ODISHA 2017 Annual 410AA0066
2 Applicant'sName SUBHADRANAIK

3 Father'sName BANAMALINAIK

4 Mother'sName SOBHANAIK
BloodGroup Sex Religion DateofBirth
O+ FEMALE HINDU 02Jun2001
5 PersonalDetails
Nationality MotherTongue AadhaarNo.
INDIAN ODIA 534478543237

6.PermanentAddress
a. State ODISHA b. District CUTTACK c. Block/ULB ATHAGARH(NAC)

d. Address ATDAHISARA,POMAHAKALABASTA,DISTCUTTACK e. PINCode 754029

f. TelephoneNo. g. MobileNo. 7381657510 h. eMail srabanionline@gmail.com

7.ReservationDetails
a. ScheduleTribe(ST) Yes ScheduleCaste(SC) No OBC No SEBC No General No

Physically/Orthopedically ServingDefence ChildrenofMartyrs


b. No ExServiceMan(ESM) No No No
Handicapped(PH/OH) Personnel(SDP) (CoM)

c. AreyouanOutsideStateApplicant(OSA)? No

AreyouanOriyaLivinginNeighbouringState
d. No
(OLNS)applicant?

8. WeightageDetails
a.NCC b.Scout&Guide c.Sports
NCC Rajya President
NCC(A) No No No No State No National No International No
(C) Puraskar(RP) Recognition(PR)

9. DetailsofMark/GradeSecuredin10thBoardExamination
Mark/Gradesecuredineach MaximumMark TotalMarkSecured English/SL Mathematics Science SocialScience Grade
a. subjectin10thBoard
600 229 53 30 30 39 E
Examination
Haveyousecuredabovemarkin
yourAnnualHSE(O)examination Yes
?
Haveyoupassed10thBoard
b. No
ExamCompartmentally?

10. IncomeDetailsofParents

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5/25/2017 CAF2017

a. Father'sOccupation CULTIVATION b. Mother'sOccupation HOMEMAKER


c. AnnualIncomeoftheParents(Together)inRs. 01,00,000

11 BankInformation
a. AccountNumber 109501000015137 b. IFSCNumber IOBA0001095
c. MICRCode 754020503 d. BankName INDIANOVERSEASBANK
e. BranchName KANTOL

12 Recordofeducationalinstitutionlastattended
a. NameoftheSchool MAHAKALABASTAHIGHSCHOOL,MADHAPUR b. LocationoftheSchool MADHAPUR
c. District CUTTACK d. YearofJoining 2014
e. YearofLeaving 2017

13Option(s)/Choice(s)Details
4thElectivesinorder Hostel
Option CollegeName Stream Compulsory Electives
ofpreference Option
Home
GopabandhuWomen's(Junior)College, Science,Language
FIRST Arts MILOdia Economics,Education,History No
Athagarh Sanskrit,Political
Science
Language
RadhanathRathVigyan(Junior)
SECOND Arts MILOdia Economics,Education,History Sanskrit,Political No
Mahavidyalaya,Khuntuni
Science,Logic
UNDERTAKING
IdoherebyagreetoabidebytherulesoftheCollege/Hostel.Iundertakethatshouldanyindisciplineanddisobedienceinstanceofthe
ruleslaiddownbytheGovernmentoranyauthorityempoweredbytheminthisregardorshouldconductinthecollegeisfoundnot
satisfactory,mynamewillautomaticallyberemovedfromthecollege.Iundertakethatinformationfurnishedbymeinthisapplicationistrue
andcorrectandiundertakethatanywronginformationfurnishedbeme,detectedafterwardswillbetreatedascognizableoffence.

Ifurtherundertakethatiwillnotinvolveinanyraggingactivitiesinthecollegeandhostelpremises.Iunderstandthatcriminalcasewillbe
filedagainstmeifindulgeinragging

Iherebyfullyendorsetheundertakingmadebyour
child/ward Submittedbyme

Signatureorthumbimpressionofparents/guardian FullSignatureofApplicant
Date Place Date Place

Enclosures(CertifiedTrueCopyofthefollowingdocumentswouldenclosedalongwiththeCAF)
Sl.# Documents
1 One(1)selfsigned(onthefrontside)recentcolorpassportsizephotographtobeaffixedintheCAF(CollegeCopy).
2 HSCMarkSheetscumProvisionalCertificate(orequivalentBoard).
ScheduleTribe(ST)/ScheduleCaste(SC)/OtherBackwardClass(OBC)certificatesfromrevenueofficernotbelowrankof
3
Tahasildar/AdditionalTahasildar.
AttestedcopyoftheBankPassBookshowingnameoftheaccountholder,accountnumber,IFSCnumberorLetterfromBank
4
Managerontheaboveinformation.
AttestedcopyofIncomeCertificateofparentsfromtheemployer/appropriateauthority(notbelowtherankofTahasildar/
5
AdditionalTahasildar).

17J1882274

http://online.dheodisha.gov.in/online_caf/CAF.aspx?BWVB+JGO9J3PMKMxYhtyRsZ7ROSjvNad 2/3
5/25/2017 CAF2017

17J1882274
CommonApplicationForm
forAdmissiontoJuniorColleges

+2
DepartmentofSchool&MassEducation,GovernmentofOdisha

ApplicantCopy
Thursday,May25,201710:18:26AM
ForOfficialuseonly

MoneyReceiptcumIndexNumber /
SignatureoftheReceivingOfficial
Fees
200.00 DateofSubmissionatCollege
(Rs.)

10thBoardDetails
1 BSE,ODISHA 2017 Annual 410AA0066
(AsinadmitCard)
2 Applicant'sName SUBHADRANAIK

3 PersonalDetails O+ FEMALE HINDU 02Jun2001 534478543237

4.ReservationDetails
a. ST Yes SC No OBC No SEBC No General No (PH/OH) No ESM No SDP No CoM No

b. AreyouanOutsideStateApplicant(OSA)? No
AreyouanOriyaLivinginNeighbouringState(OLNS)
c. No
applicant?

5. WeightageDetails
a.NCC b.Scout&Guide c.Sports

NCC(A) No NCC(C) No RajyaPuraskar(RP) No PresidentRecognition(PR) No State No National No International No

6. DetailsofMark/GradeSecuredin10thBoardExamination
Mark/Gradesecuredineach MaximumMark TotalMarkSecured English/SL Mathematics Science SocialScience Grade
a. subjectin10thBoard
600 229 53 30 30 39 E
Examination
Haveyousecuredabovemarkin
yourAnnualHSE(O)examination Yes
?
Haveyoupassed10thBoard
b. No
ExamCompartmentally?

7.Option(s)/Choice(s)Details
4thElectivesinorderof Hostel
Option CollegeName Stream Compulsory Electives
preference Option
GopabandhuWomen's(Junior)College, HomeScience,Language
FIRST Arts MILOdia Economics,Education,History No
Athagarh Sanskrit,PoliticalScience
Language
RadhanathRathVigyan(Junior)
SECOND Arts MILOdia Economics,Education,History Sanskrit,Political No
Mahavidyalaya,Khuntuni
Science,Logic

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