Common Application Form 23D2401

For Admission to Degree Colleges (2023-24)

Department of Higher Education, Government of Odisha +3
(PHASE-I)
Applicant Copy
Monday, Aug 14, 2023 05:16:54 AM

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 307NB019

2 Applicant's Name ABHIRAM SAMAL

3 Father's Name KARUNAKAR SAMAL

4 Mother's Name JALLIRANI SAMAL

Blood Group Gender Religion Date of Birth

MALE HINDUSIM 10 Apr 2005

Nationality Mother Tongue Aadhaar No. Parent Mobile No.

5 Personal Details
INDIAN ODIA ********5126 9439531864

Child without biological or adoptive parents No

6. Permanent Address

a. State ODISHA   b. District ANGUL c. Block / ULB PALLAHARA

d. Address 57, PHAPANDA, PALLAHARA e. PIN Code 759119

f. Whatsapp No. 6371224511 g. Mobile No. 6371224511

h. e-Mail abhiraamsamal107@gmail.com

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
 600  478  64  88  82  79  78

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

(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 37139577908 b. IFSC Number SBIN0007869

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

12 Record of educational institution last attended

Name of the Location of the

a. PANCHAYAT COLLEGE b. KALLA
School/College School/College
c. District DEOGARH d. Year of Joining 2021

e. Year of Leaving 2023

13 Option(s)/Choice(s) Details

Option College Stream Preference Subject Hostel Option

1st Ravenshaw University,Cuttack Biological Science HONOURS BOTANY YES

2nd Ravenshaw University,Cuttack Biological Science HONOURS ZOOLOGY YES

3rd Gangadhar Meher University, Sambalpur Biological Science HONOURS BOTANY YES

4th Gangadhar Meher University, Sambalpur Biological Science HONOURS ZOOLOGY YES

5th Dharanidhar (Autonomous) College, Keonjhar Biological Science HONOURS BOTANY YES

6th Dharanidhar (Autonomous) College, Keonjhar Biological Science HONOURS ZOOLOGY YES

7th Ispat (Autonomous) College, Rourkela Biological Science HONOURS ZOOLOGY NO

8th Government (Autonomous) College, Angul Biological Science HONOURS ZOOLOGY YES

9th Talcher (Autonomous) College, Talcher Biological Science HONOURS ZOOLOGY YES

10th Government (Autonomous) College, Angul Biological Science HONOURS BOTANY YES

Payment Details
Mode of Payment Payment Status Amount Paid Transaction No. Transaction Date
UPI SUCCESS 275.00 3444973088135