Common Application Form 24D275099

For Admission into Degree Course (2024-25)

Higher Education Department, Government of Odisha +3
(PHASE-I)
Applicant Copy
Wednesday, Jun 12, 2024 08:26:09 AM

Your CAF has not been validated. It will be verified at the time of admission. No need to visit any
SAMS Resource Center (SRC).

1 +2 Council Details Name of the Examination Board

(As in admit Card) CENTRAL BOARD OF SECONDARY EDUCATION, NEW DELHI

Year of Passing Exam Type Roll Number

2024 Annual 12648065

2 Applicant's Name BIMALENDU MOHARANA

3 Father's Name BHARAT CHANDRA MOHARANA

4 Mother's Name BISHNUPRIYA MOHARANA

Blood Group Gender Religion Date of Birth

A+ MALE HINDUSIM 24 Feb 2007
Nationality Mother Tongue Aadhaar No. Parent Mobile No.
INDIAN ODIA ********6644 9777146503
5 Personal Details
Child without biological or adoptive parents No Orphan No

Staying at Child Care Institutions No Green Passage No

Apaar ID

6. Permanent Address

a. State ODISHA b. District KALAHANDI c. Block / ULB NARLA

d. Address SARGIGUDA e. PIN Code 766110

f. Whatsapp No. 9337247153 g. Mobile No. 9337247153

h. e-Mail [email protected]

Residence
I. E-RES/2021/1250948 Not Verified
Certificate

J. Issuing Authority. Revenue Officers not below the rank of Tahasildar / Additional Tahasildar K. Issued Date. 09-10-2021

7. Reservation Details

a. Schedule Tribe No Schedule Caste No Other Backward Class No Socially and Educationally Backward Class Yes General No

b. Persons with Disabilities No

c. Ex-Service Man No Serving Defence Personnel No Children of Martyrs No

Do you have odisha domicile(Resident)

Yes
Certificate?
8. Weightage Details

a. NCC b. NSS Camp

NCC-B No NCC No International No National No State Level(Issued by No Best NSS No

Certificate (CAMP/COURSE/ACTIVITIES) Level Level State NSS Cell) Volunteer Award

c. Rover & Ranger d. Sports & Games

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

9. Details of Mark Secured in +2 or equivalent Examination

a. Stream Science

b. Mark secured in each subject in +2 or Maximum Mark Total Mark Secured English MIL Chemistry Mathematics Biology
equivalent Examination
500 293 59 52 56 54

c. Have you studied Odia at HSC/+2 Level or No

Higher (or Passed Odia as a special Exam
from BSE Odisha in 10th Standard)?

d. Have you passed +2 or equivalent Exam No

Compartmentally / Instant?

10. Income Details of Parents

Actual Income of
PRIVATE SECTOR Mother's
a. Father's Occupation b. HOME MAKER c. the Parents 90000
SERVICE Occupation
(Together)in Rs.

d. Annual Income of the Parents (Together)in Rs. 0 - 1,50,000

e. Dose your parents are paying Income Tax? No

f. Income Certificate E- Not Verified

INC/2024/1138085
Revenue Officers not
BHARAT CHANDRA Issuing below the rank of
a. To Whom the Certificate Issued b. c. Issued Date
MOHARANA Authority Tahasildar /
Additional Tahasildar

11 Bank Information

a. Account Number 39531222830 b. IFSC Number SBIN0012121

d. Bank Name STATE BANK OF INDIA e. Branch Name NARLA

f. Name of Account Holder BIMALENDU MOHARANA

Other Information

a. Special Category None of these

Does parent hold a

b. Does parents have a KALIA beneficiary? Yes c. No
Labour card?
Are you willing to participate in skilling courses Future Career Option
d. Yes e. Banker
under NASSCOM/Infosys Springboard? Desired by Applicant
 12 Record of educational institution last attended

Name of the Location of the

a. OAV CHAPATKHANDA NARLA b. NARLA KALAHANDI
School/College School/College

c. District KALAHANDI d. Year of Joining 2022

e. Year of Leaving 2024

13 Option(s)/Choice(s) Details

Option College Stream Preference Subject Hostel Option Admission Fee

1st Madanpur Rampur (Degree) College, Madanpur Rampur Biological Science HONOURS BOTANY NO 13978.00

2nd Madanpur Rampur (Degree) College, Madanpur Rampur Physical Science HONOURS CHEMISTRY NO 13978.00

3rd Maa Heera Neela (Degree) Mahavidyalaya, Biswanathpur Biological Science HONOURS BOTANY NO 17000.00

4th Maa Heera Neela (Degree) Mahavidyalaya, Biswanathpur Physical Science HONOURS CHEMISTRY NO 17000.00

5th Kesinga (Degree) Mahavidyalaya, Kesinga Biological Science HONOURS BOTANY NO 20100.00

Note: The admission fee may vary at the time of admission.

Payment Details
Mode of Payment Payment Status Amount Paid Transaction No. Transaction Date
UPI SUCCESS 275.00 9010339654012 11-06-2024

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).

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