Common Application Form

e-Admission in Govt. SSD Higher Secondary Schools

Department of School & Mass Education, Government of Odisha
XI
Name of the HSS Government SSD Higher Secondary School,Ranapatuli
SAMS Code: 16116101
For official use only

Money Receipt-cum-
Index Number /
CAF
Date of Submission at HSS
Fees

Barcode Number (will be generated after entering this Signature of the Receiving
CAF into the e-Space software) Official

Name of the Examination Board Year of Passing Roll Number

10th Board Details
1
(As in admit card)
Affix your self
Applicant's Name attested (on the
2 front) recent colour
(Full Name)
passport size
Father's Name photograph here
3
(Full Name)

Mother's Name
4
(Full Name)

Blood Group Gender (M/F) c. Religion Date of Birth e. Nationality

5 Personal Details a. b. d.

f. Mother Tongue g. Adhaar No. Parent/Guardian Mob. No. Orphan (Y/N)

h. i.

6 Permanent Address

a. State b. District c. Block/ ULB

Details (Plot / Lane /

d. e. PIN Code
Vill /PO / PS)
STD
Code
Number
Mobile WhatsApp
f. Telephone g. h.
No No

i. e-mail

j. Are you a NMMS Awardee? * Yes No

NMMS Roll
322 School Name
No

k Do You Want to avail free on-line Academic Support Programme for? (Put '√'mark)
NEET JEE Other Competitive Exam None Of these
7 Reservation Details (Please a in appropriate box)

a. Scheduled Tribe (ST) Scheduled Caste (SC) OBC SEBC General

Caste Certificate Barcode or Miscellaneous Case No.

b. Persons with Disabilities (PwD)

c. Ex-Service Man (ESM) Serving Defence Personnel (SDP) Children of Martyrs (CoM)

8 Weightage Details (Please a in appropriate box)

a. NCC b. Scout & Guide c. Sports

Rajya Puraskar President
NCC (A) State National International
(RP) Recognition (PR)

NCC (C)

9 Details of marks secured in 10th Board Examination

Marks secured in subjects English Mathematics Science Social Science Total Mark Secured Maximum Mark
a. specified in 10th Board
Examination

Marks secured in Marks secured in

Have you passed 10th Board Yes No Name of the Subject
b. If yes previous exam Compartmental exam
Exam Compartmentally?

10 Income Details of Parents

a. Father's Occupation b. Mother's Occupation

c. Annual Income of the Parents (Together) in Rs.

11 Bank Information
a. Account Number b. IFSC Number

c. MICR Code d. Bank Details

e. Branch Name

12 Record of Educational Institution Last Attended

Location of the
a. School Name b.
School

c. District d. Year of Joining

Permanent
e. Year of Leaving e. Education
Number(PEN)
13 Option(s)/Choice(s) Details
First Option

a. Stream Name b. Compulsory (MIL)

Elective First Elective Second Elective Third Elective

c.
Subject

4th First Choice Second Choice Third Choice

d.
Elective

e. Are you interested to reside in hostel Yes No

Second Option

a. Stream Name b. Compulsory (MIL)

Elective First Elective Second Elective Third Elective

c.
Subject

4th First Choice Second Choice Third Choice

d.
Elective

e. Are you interested to reside in hostel Yes No

Third Option

a. Stream Name b. Compulsory (MIL)

Elective First Elective Second Elective Third Elective

c.
Subject

4th First Choice Second Choice Third Choice

d.
Elective

e. Are you interested to reside in hostel Yes No

I do hereby agree to abide by the rules of the HSS / Hostel. I undertake that should any instance of indiscipline and
disobedience of the rules laid down by the Government or any authority empowered by them in this regard, or should my
conduct in the HSS is found not satisfactory, my name will be automatically be removed from the HSS. I also undertake that
the information furnished by me in this application is true and correct. Should any information furnished by me is detected
wrong afterwards, it 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 I indulge in ragging.

I am also agreeing to all the terms & conditions with regard to the e-Admission mentioned in the Common Prospectus.

I hereby fully endorse the undertaking made by our

Submitted by me
child/ward

Signature or thumb impression of parents/ guardian Full Signature of Applicant

Date Place Date Place