Common Application Form 22H0765792

Admission to Higher Secondary School  

Academic Session (2022-23)
Department of School & Mass Education, Government of Odisha XI
Phase - I
Thursday, Jul 21, 2022 11:50:13 AM
Note:-This CAF Applicant Copy is required to submit at the time of admission.

1. 10th Board Details Name of the Examination Board Year of Passing Exam Type Roll Number
(As in Admit Card) BSE, ODISHA 2022 Annual 198AD0043

2. Applicant's Name SASWATI MISHRA

3. Father's Name MAHESWARA MISHRA

4. Mother's Name JYOTIREKHA MISHRA

5. Personal Details Blood Group   Sex   Religion   Date of Birth  
  FEMALE   HINDUISM   08-Feb-2007  
Nationality Mother Tongue Aadhaar No. Guardian Mobile No. Orphan
INDIAN ODIA 771724897602 7846948011 No
     

6. Address for Correspondence

a. State ODISHA   b. District JAJPUR c. Block / ULB JAJPUR

d. Address MATABAD , MALANDPUR , KAMAGARH , BARUHNA e. PIN Code 755043

Mobile Whatsapp
f. Telephone No.     g. 7846948011   h. 7846948011 i. e-Mail abhisekmishra259@gmail.com
No. No.

7. Reservation Details
a. Schedule Tribe No Schedule Caste No Other Backward Class No Socially and Educationally Backward Classes No General Yes

b. Persons with Disabilities No Ex-Service Man No Serving Defence Personnel No Children of Martyrs No

8. Weightage Details
   
NCC Scout & Guide Sports

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

9. Details of Mark/Grade Secured in 10th Board Examination

a. Mark/Grade secured in each subject in
Maximum Mark Total Mark Secured English/SL Mathematics Science Social Science Grade
10th Board Examination
  600   474   81   61   75   71   B1

b. Have you passed 10th Board Exam No  

Compartmentally ?

10. Income Details of Parents

a. Father's Occupation PRIVATE SECTOR SERVICE b. Mother's Occupation NOT APPLICABLE

c. Annual Income of the Parents (Together)in Rs. 0-1,00,000

 11. Bank Information

a. Account Number 408534002004415 b. IFSC Number IOBA0ROGB01

c. MICR Code 755706519 d. Bank Name INDIAN OVERSEAS BANK

e. Branch Name IOB, RRB, ODISHA GRAMYA BANK

12. Record of educational institution last attended

GRAMA MANGAL SAMITI NODAL HIGH SCHOOL,

a. Name of the School b. Location of the School RURHIYA , JAJPUR
RURHIYA

c. District JAJPUR d. Year of Joining 2019

e. Year of Leaving 2022 f. Student Unique ID

13. Option(s)/Choice(s) Details

Option HSS Name Stream Compulsory Electives 4th Electives inorder of Hostel
preference Option

1st Maa Tarini Higher Secondary School, Panikoili Science MIL Odia Physics,Chemistry,Biology Mathematics No

2nd Braja Sundar Higher Secondary School, Science MIL Odia Physics,Chemistry,Biology Mathematics No
Sayedpur

3rd Biraja Women's Higher Secondary School, Jajpur Science MIL Odia Physics,Chemistry,Biology Mathematics No

4th Baruneswar Higher Secondary School, Arei Science MIL Odia Physics,Chemistry,Biology Mathematics No

5th Chitalo Higher Secondary School, Chitalo Science MIL Odia Physics,Chemistry,Biology Mathematics No

Payment Details

Mode of Payment Payment Status Amount Paid Transaction No. Transaction Date

ONLINE SUCCESS 200.00 1635919780738 21/07/2022

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

2 True Copy of HSC Mark Sheets-cum-Provisional Certificate (or equivalent Board).

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