Common Application Form 19D013206

for Admission to Degree Colleges (2019-20)

Department of Higher Education, Government of Odisha
College Copy +3
Friday, Aug 16, 2019 09:16:58 PM

For Official use only

Money Receipt-cum-Index Number College Code / Index No.  

Fees (Rs.) 275.00 Date of Submission at College     Signature of the

Receiving Official

Name of the Examination Year of

Exam Type Roll Number
+2 Council Details Board Passing
1
(as in admit Card)
CHSE, ODISHA 2019 Annual 211MA074

2 Applicant's Name SURYAKANT SAHOO

3 Father's Name BIJAY KUMAR SAHOO

4 Mother's Name PRAVASHINI SAHOO

Blood Group   Gender   Religion   Date of Birth Affix your self attested
(on the front) recent
MALE   HINDU   23 Sep 2000   color passport size
5 Personal Details photographs here
Nationality Mother Tongue Aadhaar No.

INDIAN ODIA 357874953659

6.    Permanent Address

a. State ODISHA   b. District KHURDA c. Block / ULB BHUBANESWAR (MC)

d. Address PLOT NO-3534, MULAPADIA, PARAKARANA SAHI, OLD TOWN e. PIN Code 751002

Telephone Mobile
f.     g. 8917366020 h. e-Mail suryakantsahoo399@gmail.com
No. No.

7.    Reservation Details

 Schedule Caste
a.  Schedule Tribe (ST)  No No OBC No  SEBC No  General Yes
(SC)

 Physically/Orthopedically Ex-Service Man Serving Defence Children of Martyrs

b. No No No No
Handicapped (PH/OH) (ESM) Personnel (SDP) (CoM)
8. Weightage Details

a.   NCC   b.   NSS Camp

NCC NCC University Level No State Level No National Level No International Level No
No No
B (CAMP/COURSE)

c.   Rover & Ranger   d. Sports & Games

Rajya Puraskar(RP) No President Recognition(PR) No State No National No International No

9. Details of Mark Secured in +2 Council Examination

a. Stream  Commerce

Maximum Mark Total Mark Secured MIL English

Mark secured in each subject in
b.
+2 Council Examination  600  248  30  30

Have you secured above mark in

your Annual CHSE(O) examination Yes
?

Have you passed +2 Council

c. Exam Compartmentally  / Instant No  
?

10. Income Details of Parents

a. Father's Occupation BUSINESS 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 555910110006657 b. IFSC Number BKID0005559

c. MICR Code d. Bank Name bank of India

e. Branch Name kapilprasad

12 Record of educational institution last attended

a. Name of the School EKAMRA H S SCHOOL BHUBANESWAR b. Location of the School kapilprasad

c. District KHURDA d. Year of Joining 2017

e. Year of Leaving 2019

13    Option(s)/Choice(s) Details

Option College Stream Preference Subject Hostel Option

FIRST Buxi Jagabandhu Bidyadhar (Autonomous) College, Bhubaneswar Commerce HONOURS COMMERCE,, NO

SECOND Biju Pattnaik (Degree) College of Science & Education, Jayadev Vihar Commerce HONOURS COMMERCE,, NO

THIRD Maharishi (Degree) College of Natural Law, Bhubaneswar Commerce HONOURS COMMERCE,, NO

FOURTH Rajdhani (Degree) College, Bhubaneswar Commerce HONOURS COMMERCE,, NO

FIFTH Deb Ray (Degree) College, Nayapalli Commerce HONOURS COMMERCE,, NO

SIXTH Ekamra (Degree) College, Bhubaneswar Commerce HONOURS COMMERCE,, NO

Payment Details

Mode of Payment Payment Status Amount Paid Transaction No.

DC SUCCESS 275.00 0531728623105

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).

Higher Secondary (+2) Mark Sheets-cum-Provisional Certificate (or equivalent Board). If an applicant has not received the mark sheet
2 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.

19D013206
 19D013206
Common Application Form
for Admission to Degree Colleges (2019-20)
Department of Higher Education, Government of Odisha
Applicant Copy +3
Friday, Aug 16, 2019 09:16:58 PM

For Official use only

Money Receipt-cum-Index  
College Code / Index No.
Number
Signature of the Receiving
Fees (Rs.)  275.00 Date of Submission at College   Official

+2 Council Details
1 CHSE, ODISHA 2019 Annual 211MA074
(as in admit Card)

2 Applicant's Name SURYAKANT SAHOO

3 Personal Details   MALE   HINDU   23 Sep 2000   357874953659

4.    Reservation Details

a. ST   No   SC  No    OBC No  SEBC No  General Yes   PH/OH  No   ESM  No   SDP  No   CoM  No

5. Weightage Details

a.   NCC   b.   NSS Camp

NCC NCC University Level No State Level No National Level No International Level No
No No
B (CAMP/COURSE)

c.   Rover & Ranger   d. Sports & Games

Rajya Puraskar(RP) No President Recognition(PR) No State No National No International No

6. Details of Mark Secured in +2 Council Examination

a. Stream  Commerce

Maximum Mark Total Mark Secured MIL English

Mark secured in each subject in
b.
+2 Council Examination  600  248  30  30

Have you secured above mark in

your Annual CHSE(O) examination Yes
?

Have you passed +2 Council

c. Exam Compartmentally / Instant  No  
?

7.   Option(s)/Choice(s) Details

Option College Stream Preference Subject Hostel Option

FIRST Buxi Jagabandhu Bidyadhar (Autonomous) College, Bhubaneswar Commerce HONOURS COMMERCE,, NO

SECOND Biju Pattnaik (Degree) College of Science & Education, Jayadev Vihar Commerce HONOURS COMMERCE,, NO

THIRD Maharishi (Degree) College of Natural Law, Bhubaneswar Commerce HONOURS COMMERCE,, NO

FOURTH Rajdhani (Degree) College, Bhubaneswar Commerce HONOURS COMMERCE,, NO

FIFTH Deb Ray (Degree) College, Nayapalli Commerce HONOURS COMMERCE,, NO

SIXTH Ekamra (Degree) College, Bhubaneswar Commerce HONOURS COMMERCE,, NO

Payment Details

Mode of Payment Payment Status Amount Paid Transaction No.

DC SUCCESS 275.00 0531728623105