Common Application Form 23H3836534

Admission to Higher Secondary School  

Academic Session (2023-24)
Department of School & Mass Education, Government of Odisha XI
Phase - I
Monday, Jun 12, 2023 05:21:03 PM
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 2021 Annual 136cc0230

2. Applicant's Name SHILA KHUNTIA

3. Father's Name SHARMA KHUNTIA

4. Mother's Name URMILA KHUNTIA

5. Personal Details Blood Group Gender Religion Date of Birth

O+ FEMALE HINDUISM 07-Sep-2006

Nationality Mother Tongue Aadhaar No. Guardian Mobile No. Orphan

INDIAN ODIA 389371224844 9853784283 No

6. Address for Correspondence

a. State ODISHA b. District KEONJHAR c. Block / ULB JODA

d. Address AT-GUALI PO-GUALI PS-GUALI DIST KJR PIN-758035 e. PIN Code 758035

Whatsapp
f. Telephone No. g. Mobile No. 9853784283 h. 9853784283 i. e-Mail shilakhuntia@gmail.com
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 NMMS Awardee 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
600 370 56 79 46 53 B2

b. Have you passed 10th Board Exam No

Compartmentally ?

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

SAMS Application © 2023-2024

 11. Bank Information

a. Account Number 543510110008487 b. IFSC Number BKID0005435

c. MICR Code d. Bank Name BANK OF INDIA

e. Branch Name BHADRASAHI

12. Record of educational institution last attended

a. Name of the School NILACHAL HIGH SCHOOL, GUALI b. Location of the School GUALI

c. District KEONJHAR d. Year of Joining 2009

e. Year of Leaving 2021 f. Student Unique ID

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

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

1st Rimuli Higher Secondary School, Rimuli Science MIL Odia Physics,Chemistry,Biology Mathematics No

2nd Angarpada Panchayat Higher Secondary School, Raruan Science MIL Odia Physics,Chemistry,Biology Mathematics No

3rd Barbil Higher Secondary School, Barbil Science MIL Odia Physics,Chemistry,Biology Geology,Mathematics No

4th Jhumpura Panchayat Samiti Higher Secondary School, Science MIL Odia Physics,Chemistry,Biology Mathematics No
Jhumpura

5th Chandra Sekhar Higher Secondary School, Champua Science MIL Odia Physics,Chemistry,Biology Geology,Mathematics No

Payment Details

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

ONLINE SUCCESS 200.00 YHMP1933575291 12/06/2023

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).

SAMS Application © 2023-2024

SAMS Application © 2023-2024