18/06/2024, 12:01 SAMS :: Student Academic Management System

Common Application Form 24H3407697

Admission to Higher Secondary School
Academic Session (2024-25)
Department of School & Mass Education, Government of Odisha
XI
Phase - I

Tuesday, Jun 18, 2024 12:01:35 PM

Note:-This CAF Applicant Copy is required to submit at the time of admission.

1. 10th Board Details Name of the Examination Board Year of Passing Exam Type Roll Number
(As in Admit Card) CBSE, NEW DELHI 2024 Annual 12164790

2. Applicant's Name PRANATI PRAGYANRANI NAIK

3. Father's Name JOGESH CHANDRA NAIK

4. Mother's Name MAMINA NAIK

5. Personal Details Blood Group Gender Religion Date of Birth
B+ FEMALE HINDUISM 08-Apr-2009
Nationality Mother Tongue Aadhaar No. Guardian Mobile No. Orphan
INDIAN ODIA ********4217 6371385182 No

6. Address for Correspondence

a. State ODISHA b. District KEONJHAR c. Block / ULB JHUMPURA

d. Address AT/PO-ASANPAT PS-BARIA KEONJHAR e. PIN Code 758032

Whatsapp
f. Telephone No. g. Mobile No. 6371385182 h. 6371385182 i. e-Mail
No.

J. NMMS Awardee No

K. NEET/JEE Details

NEET JEE Other Competitive Exams None Of These

No No No Yes

7. Reservation Details
a. Schedule Tribe Yes Schedule Caste No Other Backward Class No Socially and Educationally Backward Classes No General No

b. Persons with Disabilities No Ex-Service Man No Serving Defence Personnel No Children of Martyrs No

8. Weightage Details

NCC Scout & Guide Sports

NCC (A) No NCC (C) No Rajya Puraskar(RP) No President Recognition(PR) No State No National No International No

9. Details of Mark/Grade Secured in 10th Board Examination

a. Mark/Grade secured in each subject in Maximum Mark Total Mark Secured English/SL Mathematics Science Social Science
10th Board Examination
500 317 71 45 39 74

b. Have you passed 10th Board Exam No

Compartmentally ?

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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 203434006006531 b. IFSC Number IOBA0ROGB01

c. MICR Code d. Bank Name INDIAN OVERSEAS BANK

e. Branch Name IOB, RRB, ODISHA GRAMYA BANK

12. Record of educational institution last attended

a. Name of the School EMRS RANKI KEONJHAR b. Location of the School KEONJHAR

c. District KEONJHAR d. Year of Joining 2020

e. Year of Leaving 2024

13. Option(s)/Choice(s) Details

Option HSS Name Stream Compulsory Electives 4th Electives inorder of preference Hostel Option

1st KSE Science Higher Science MIL Odia Physics, Chemistry, Mathematics Biology Yes
Secondary School

2nd Government Women's Science MIL Odia Physics, Chemistry, Mathematics Biology Yes
Higher Secondary
School, Keonjhar

3rd Dharanidhar Higher Science MIL Odia Physics, Chemistry, Mathematics Biology Yes
Secondary School,
Keonjhar

4th Padmapur Anchalika Science MIL Odia Physics, Chemistry, Mathematics Biology No
Higher Secondary
School, Padmapur

5th Jhumpura Panchayat Science MIL Odia Physics, Chemistry, Mathematics Biology No
Samiti Higher
Secondary School,
Jhumpura

Payment Details

Mode of Payment Payment Status Amount Paid Transaction No. Transaction Date

ONLINE SUCCESS 100.00 ZIC52081017104 18/06/2024

UNDERTAKING
I do hereby agree to abide by the rules of the HSS/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 HSS is found not satisfactory, my name will automatically be
removed from the HSS. 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 HSS 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 (Certified True Copy of the following documents would enclosed along with the CAF)

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Sl# Documents

1 One (1) self signed (on the front side) recent color passport size photograph to be affixed in the CAF (HSS Copy).

2 True Copy of HSC Mark Sheets-cum-Provisional Certificate (or equivalent Board).

3 Scheduled Tribe (ST) / Scheduled Caste (SC) / Other Backward Classes (OBC) certificates from revenue officer not below rank of Tahasildar /
Additional Tahasildar.

4 Migration Certificate for the applicant from Boards other than BSE, Odisha.

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