8/3/2021 CAF-2021

Common Application Form

for Admission to Government & Private ITIs  (2021-22)
Skill Development and Techincal Education Department, Government of Odisha
Tuesday, Aug 3, 2021 03:53:13 PM

Your application is not validated. 21T0173057

Date of Submission at Institue        
Signature of the Receiving
Official

1 Qualification 10th Pass

Name of the Examination Board Year of Passing Exam Type Roll Number
2 10th Board Details Board of Secondary Education , 2021 Annual 322DB0155
Odisha ,Cuttack-01

3 Applicant's Name JUDHISTIRA PRADHAN

4 Father's Name INDRA PRADHAN

5 Mother's Name BISHNU PRADHAN

Sex   Religion   Date of Birth

6 Personal Details
MALE   HINDU   11 Mar 2006

7. Highest Qualification
  10th

8.    Resident Address
a. State ODISHA   b. District GANJAM c. Block / ULB PATRAPUR

d. Address MARDARAJPUR, KELUA e. PIN Code 761004

f. Telephone No.     g. Mobile No. 6370352033 h. e-Mail kp153518@gmail.com

Aadhaar Card
i. Alternate Mobile No. NA   j. 292802353829 k. Ration Card No. NA
No.

9.    Bank Details

a. Name of Bank NA   b. Branch Name NA c. Account No. NA

d. IFSC Code NA

10. Reservation Details

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

Persons with Disability

b. No Sports No Green Card No Minority No
(PwD)

PVTG (Particularly vulnerable

c. Ex-Service Man (ESM) No None CRPF No Police No
tribal group)

d. Whether Parent working in any Government/PSU/Defense sector in Odisha : No

e. Whether parent belongs to Building and construction worker No

Do you belong to Economically Weaker Sections (EWS) category ? No

11. Income Details of Parents

Are you an orphan ? No

Annual Income of the Parents 0-

a. Father's Occupation CULTIVATION b. Mother's Occupation
  HOME MAKER c.
(Together) in Rs. 1,00,000

d. Income Certificate Number NA e. Income Certificate Status NA

https://skill.samsodisha.gov.in/ManageStudentITI/ITICAFPrint.aspx?enc=hM5dHuFhXqyiyaeIsABpMXZdtdcfTeUnSqS6la0TLyDzm9bZrbqzJ9MUT… 1/2
8/3/2021 CAF-2021

12.Details of Mark/Grade Secured in Examination

Total Mark English Math Science Social Science Grade
Total Mark Secured Maximum Secured Maximum Secured Maximum Secured Maximum Secured Secured
600 360 100 50 100 64 100 64 100 59 B2

b. Have you passed 10th Board Exam Compartmentally ? No  

Payment Details
Mode of Payment Payment Status Amount Paid Transaction No.
Online SUCCESS 100 WSM20165175624

13    Option(s)/Choice(s) Details
Option Institute Name Trade Hostel Option IMC / REGULAR
1st ITI Berhampur, Ganjam - Berhampur (MC) Electrician (NSQF) Yes REGULAR
2nd ITI Berhampur, Ganjam - Berhampur (MC) Electronics Mechanic (NSQF) Yes REGULAR
3rd ITI Berhampur, Ganjam - Berhampur (MC) Fitter (NSQF) Yes REGULAR
4th ITI Berhampur, Ganjam - Berhampur (MC) Machinist (NSQF) Yes REGULAR
5th ITI Berhampur, Ganjam - Berhampur (MC) Turner (NSQF) Yes REGULAR
6th ITI Berhampur, Ganjam - Berhampur (MC) Instrument Mechanic (NSQF) Yes REGULAR
7th ITI Berhampur, Ganjam - Berhampur (MC) Technician Mechatronics (NSQF) Yes REGULAR
8th ITI Berhampur, Ganjam - Berhampur (MC) Mechanic (Motor Vehicle) (NSQF) Yes REGULAR
9th ITI Berhampur, Ganjam - Berhampur (MC) Surveyor(NSQF) Yes REGULAR

UNDERTAKING
I do hereby agree to abide by the rules of the Institue /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 Institue is found not satisfactory, my name will automatically be removed from
the Institue . 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 Institue
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  

Note:-"For Availing district Quota" please attach copy of residence certificate/Any

government issued ID Card (like Voter ID Card, Aadhaar Card, Electricity bill, Driving
License, etc. of Parents)
Enclosures (Certified True Copy of the following documents
would be 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).
3 Migration Certificate for the applicant from Boards other than BSE, Odisha.
4 School Leaving Certifcate from the School
5 Attested copy of the Bank Pass Book showing name of the account holder,account number, IFSC number or Letter from Bank Manager on the above information.
6 Attested copy of Income Certificate of parents from the employer / appropriate authority (not below the rank of Tahasildar / Additional Tahasildar) .

https://skill.samsodisha.gov.in/ManageStudentITI/ITICAFPrint.aspx?enc=hM5dHuFhXqyiyaeIsABpMXZdtdcfTeUnSqS6la0TLyDzm9bZrbqzJ9MUT… 2/2