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Common Application Form 24D173807

For Admission into Degree Course (2024-25)
Higher Education Department, Government of Odisha +3
Applicant Copy (PHASE-I)

Saturday, Jun 8, 2024 09:46:10 PM

Your CAF has been Validated. It will be checked 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

2022 Annual 105mc025

2 Applicant's Name PURNA CHANDRA PAIKARAY

3 Father's Name PRADYUMNA PAIKARAY

4 Mother's Name CHHABI PAIKARAY

Blood Group Gender Religion Date of Birth

B+ MALE HINDUSIM 22 Feb 2005
Nationality Mother Tongue Aadhaar No. Parent Mobile No.
INDIAN ODIA ********0722 6370347496
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 PURI c. Block / ULB BRAHMAGIRI

d. Address AT/PO-BHANDARIKUDA,VIA-BRAHMAGIRI,PURI e. PIN Code 752011

f. Whatsapp No. 9827978235 g. Mobile No. 9827978235

h. e-Mail pcpaikaray0@gmail.com

7. Reservation Details

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

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

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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 Mathematics
equivalent Examination
600 249 41 50 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

Actual Income of
Mother's
a. Father's Occupation CULTIVATION b. HOME MAKER c. the Parents 100000
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/2024/938021
Revenue Officers not
REVENUE Issuing below the rank of
a. To Whom the Certificate Issued b. c. Issued Date 22-05-2024
OFFICERS Authority Tahasildar / Additional
Tahasildar

11 Bank Information

a. Account Number 42220563391 b. IFSC Number SBIN0012038

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

f. Name of Account Holder PURNA CHANDRA PAIKARAY

Other Information

a. Special Category None of these

Does parent hold a

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

12 Record of educational institution last attended

Name of the Location of the

a. BRAHMESWAR H S SCHOOL, DHARMAKRITI b. DHARMAKIRTI
School/College School/College
c. District PURI d. Year of Joining 2020

e. Year of Leaving 2022

13 Option(s)/Choice(s) Details

Option College Stream Preference Subject Hostel Option Admission Fee

1st Bhakta Manein Smruti Degree Mhv., Kandagoda Arts HONOURS ODIA NO 6500.00

2nd B.J.B. (Degree) College, Gadarodanga Arts HONOURS ODIA NO 7000.00

3rd Brahmeswar (Degree) Mahavidyalaya, Dharmakriti Arts HONOURS ODIA NO 3600.00

4th Hariswar Dev Vocational Science (Degree) College, Panaspada Arts HONOURS ODIA NO 6720.00

5th Alarnath Dhandamulak (Degree) Mahavidyalaya, Brahmagiri Arts HONOURS ODIA NO 11290.00

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

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Payment Details
Mode of Payment Payment Status Amount Paid Transaction No. Transaction Date
UPI SUCCESS 275.00 4644049642730 09-06-2024

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.

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