6/5/24, 9:26 PM SAMS::Student Academic Management System

Common Application Form

B.Ed, B.H.Ed,M.Ed Courses
Higher Education Department, Odisha, Bhubaneswar
24TE020428587
Wednesday, June 5, 2024, 09:25 PM

Candidate Personal Details

Course : B.Ed Photo

Applicant's Type : FRESH

Applicant's Name : HARAPRASAD DAS

Mother's Name : KUNILATA BHOI

Father/Husband/ Guardian Name : PRAVAKAR BHOI

Gender : MALE Date of Birth : 17-Apr-2002

Email : haradas12045@gmail.com

Aadhaar No : XXXXXXXX1638

APAAR ID : NA
Signature
Mobile No. : 9337262641 Whatsapp No. : 9337262641

Alternate Mobile No : NA

Marital Status : UNMARRIED Examination center : Puri(26)

Graduation : Passed

Social Category : SC Reserve Category : NA

Caste certificate : E-SCO/2020/139547 (Not Verified)

Revenue Officers not below the rank of

Caste Issuing Authority : Date of Caste Certificate Issuance: 05-Oct-2020
Tahasildar / Additional Tahasildar
Have you studied Odia at HSC/+2 Level (or Passed Odia as a special Exam from BSE Odisha in 10th Standard) ? : Yes

Opted for Hostel. : Yes Green Passage Scheme : No

Child with Biological Parents : Yes Orphan : No

Staying at Child Care Institution : No

Present Address

Address Line-1 : BIRARAMCHANDRAPUR Address Line-2 : SATYABADI

Country : India State : Odisha

District : Puri Pincode : 752014

Block : Satyabadi

Permanent Address

Address Line-1 : BIRARAMCHANDRAPUR Address Line-2 : SATYABADI

Country : India State : Odisha

District : Puri Pincode : 752014

Residence Certificate E-RES/2023/1830460 (Not Verified)

Block : Satyabadi Barcode :

Revenue Officers not below the rank of Tahasildar / Date of Residence

Residence Issuing Authority : 03-Oct-2023
Additional Tahasildar Certificate Issuance :

Other Information
Special Category (For GSSY
None of these KALIA beneficiary No
Scholarship)
:
:
Labour card No
:

https://te.samsodisha.gov.in/ManageStudent/BEDCafPrint.aspx?enc=YedqSyRrV1Z99C/l8tGdWO/unEHditIIKUlMzVEe097rQ+A0ZQKjwtDufGOAk398… 1/2
6/5/24, 9:26 PM SAMS::Student Academic Management System

Income details of Parents

Father/Husband/Guardian
GOVT.SERVICE Mother's Occupation HOME MAKER
Occupation
:
Annual Income of the :
2,50,000-8,00,000 Actual Annual Income (In Rs) 400000
parents(together) in Rs.
:
:
NOT PROVIDED To Whom the Certificate is
Income Certificate Barcode NOT PROVIDED
Issued
:
:
Date of Income Certificate
Income Issuing Authority NOT PROVIDED NOT PROVIDED
Issuance
:
:
Stream

Stream Name

Science/BTech/BE

Educational Qualification

Mark Maximum Mark

Examination Passed College Board Year Of Passing RollNo Percentage
Type Mark Obtained
Graduation Utkal University 2023 32020011 Mark 2600 1638 63.00

Scholarship
* Based on the given information, you are provisionally eligible to apply for the following scholarship scheme. Please register at Scholarship Portal to apply different scholarships.

Note: Please refer to the respective scholarship guidelines and datelines for more information.

SL# Department Name Scholarship Scheme

1 Higher Education Department NUA-O Scholarship

Payment Details

Payment Date Payment Amount Transaction Number Payment Mode Payment Through
05-Jun-2024 300.00 113317406091 Unified Pa HDFC

Bank Account Details

Account Number 36096736633 AccountHolder Name HARAPRASAD DAS

: :
IFSC Code SBIN0013599 MICR Code
: :
Bank Name STATE BANK OF INDIA Branch Name RANAPUR
: :
Declaration

I HARAPRASAD DAS do hereby declare that all the information furnished by me in this application form is true and complete to the best of my knowledge and belief. I
understand that entries made by me in this application form are final binding on me.

Note:- The CAF Fees of the applicants coming under "welfare classification" will be refunded after verification by the concerned DCPO and DSWO.

Place: Date: Signature of the candidate:

24TE020428587

https://te.samsodisha.gov.in/ManageStudent/BEDCafPrint.aspx?enc=YedqSyRrV1Z99C/l8tGdWO/unEHditIIKUlMzVEe097rQ+A0ZQKjwtDufGOAk398… 2/2