Common Application Form 23D267527

For Admission to Degree Colleges (2023-24)

Department of Higher Education, Government of Odisha +3
Applicant Copy (PHASE-I)

Your application is auto-validated. No need to submit the print out copy at any
SAMS Resource Center (SRC).
Note:-This CAF Applicant Copy is required to submit at the time of admission.

1 +2 Council Details Name of the Examination Board

(As in admit Card) COUNCIL OF HIGHER SECONDARY EDUCATION, ODISHA

Year of Passing Exam Type Roll Number

2023 Annual 107hc070

2 Applicant's Name PUSPANJALI GOUDA

3 Father's Name PARAMANANDA GOUDA

4 Mother's Name CHANDINI GOUDA

Blood Group Gender Religion Date of Birth

O+ FEMALE HINDUSIM 20 May 2006
Nationality Mother Tongue Aadhaar No. Parent Mobile No.
5 Personal Details
INDIAN ODIA ********3032 9668435675

Child without biological or adoptive parents No

6. Permanent Address

a. State ODISHA   b. District NAWARANGPUR c. Block / ULB JHARIGAM

d. Address AT-SIRAGUDA PO-JHARIGAM PS-JHARIGAM e. PIN Code 764076

f. Whatsapp No. 9692711988 g. Mobile No. 9692711988

h. e-Mail GOUDAPUSPANJALI123@GMAIL.COM

7. Reservation Details

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

No
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 Arts

b. Mark secured in each subject in +2 or Maximum Mark Total Mark Secured English MIL Chemistry Mathematics Biology
equivalent Examination
 600  371  47  70  0  0  0

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

a. Father's Occupation CULTIVATION 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 52728100010241 b. IFSC Number BARB0UMARKO

d. Bank Name BANK OF BARODA e. Branch Name UMARKOTE

12 Record of educational institution last attended

Name of the Location of the

a. JHARIGAM MAHAVIDYALAYA b. JHARIGAM
School/College School/College
c. District NAWARANGPUR d. Year of Joining 2021

e. Year of Leaving 2023

13 Option(s)/Choice(s) Details

Option College Stream Preference Subject Hostel Option

1st Vikram Dev University, Jeypore Arts HONOURS POLITICAL SCIENCE YES

2nd Pendrani (Degree) Mahavidyalaya, Umerkote Arts HONOURS POLITICAL SCIENCE NO

3rd Panabedha (Degree) Mahavidyalaya, Chandahandi Arts HONOURS POLITICAL SCIENCE NO

4th Model Degree College, Nawarangpur Arts HONOURS POLITICAL SCIENCE NO

5th Bhairab (Degree) College, Dabugan Arts HONOURS POLITICAL SCIENCE NO

Payment Details
Mode of Payment Payment Status Amount Paid Transaction No. Transaction Date
NB SUCCESS 275.00 5865461597233