Common Application Formfor Admission to Junior Colleges (2014-15)

Department of Higher Education, Government of Odisha

Saturday, Jun 7, 2014 10:15:22 AM

14J0543578

+2

Money Receipt-cum-Index Number /

Fees(Rs.)

200.00 Date of Submission at College

Signature of the ReceivingOfficial

110th Board Details (As in admit Card)

Name of theExamination Board

Year ofPassing

Exam Type Roll Number

BSE, ODISHA 2014 Annual 018CC043

2 Applicant's Name SIDHESWAR PRADHAN

3 Father's Name FAKIRA CHARAN PRADHAN

4 Mother's Name SABITA RANI PRADHAN

5 Personal DetailsBlood Group Sex Religion Date of Birth

O+ MALE HINDU 14-Nov-1998

Affix your self attested (on

the front) recent color

passport size photographs

here

6. Address for Correspondence

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

d. Address AT/PO- BALIBANDH e. PIN Code 758031

f.TelephoneNo.

g.MobileNo.

8908078722 h. e-Mail amreshpradhan@hotmail.com

7. Reservation Details

a. Schedule Tribe (ST) No Schedule Caste(SC)

No Others Yes

b. Physically/OrthopedicallyHandicapped (PH/OH)

No Ex-Service Man(ESM)

No Serving DefencePersonnel (SDP)

No Children ofMartyrs (CoM)

No

c. Are you an Outside State Applicant (OSA)? No

d.Are you an Oriya Living in Neighbouring State(OLNS)applicant ?

No

8. Weightage Details

a. NCC

NCC (A) NoNCC(C)

No

b. Scout & Guide

RajyaPuraskar(RP)

NoPresidentRecognition(PR)

No

c. Sports

State No National No International No

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

a.Mark/Grade secured in eachsubject in 10th BoardExamination

Maximum

Mark

Total Mark

SecuredEnglish Mathematics Science

Social

ScienceGrade

600 409 60 60 58 63 B2

Have you secured above markin your Annual HSE(O) Yes

examination ?

b.Have you passed 10th BoardExam Compartmentally ?

No

10 Option(s)/Choice(s) Details

Option College Name Stream Compulsory Electives4th Electives in

order of preferenceHostelOption

FIRSTChandra Sekhar (Junior) College,Champua

Science MIL Oriya Physics,Chemistry,Biology Mathematics,Geology Yes

SECOND Rimuli (Junior) College, Rimuli Science MIL Oriya Physics,Chemistry,Biology Mathematics No

THIRDJhumpura Panchayat Samiti (Junior)College, Jhumpura

Science MIL Oriya Physics,Chemistry,Biology Mathematics Yes

UNDERTAKING

I do hereby agree to abide by the rules of the College/Hostel. I undertake that should any indiscipline and disobedience instanceof the rules laid down by the Government or any authority empowered by them in this regard or should conduct in the college isfound not satisfactory, my name will automatically be removed from the college. I undertake that information furnished by me inthis application is true and correct and i undertake that any wrong information furnished be me, detected afterwards will betreated as cognizable offence.

I further undertake that i will not involve in any ragging activities in the college and hostel premises. I understand that criminalcase will be filed against me if indulge in ragging

I hereby fully endorse the undertaking made byour

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)

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 HSC Mark Sheets-cum-Provisional Certificate (or equivalent Board).

14J0543578

Common Application Formfor Admission to Junior Colleges

Department of Higher Education, Government of Odisha

Applicant Copy Saturday, Jun 7, 2014 10:15:22 AM

14J0543578

+2

For Official use only

Money Receipt-cum-Index Number /

Fees(Rs.)

200.00 Date of Submission at College

Signature of the Receiving Official

110th Board Details (As in admit Card)

BSE, ODISHA 2014 Annual 018CC043

2 Applicant's Name SIDHESWAR PRADHAN

3 Personal Details O+ MALE HINDU 14-Nov-1998

4. Reservation Details

a. ST No SC No Others Yes (PH/OH) No ESM No SDP No CoM No

b. Are you an Outside State Applicant (OSA) ? No

c.Are you an Oriya Living in Neighbouring State (OLNS)applicant ?

No

5. Weightage Details

a. NCC

NCC(A)

NoNCC(C)

No

b. Scout & Guide

RajyaPuraskar(RP)

NoPresidentRecognition(PR)

No

c. Sports

State No National No International No

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

a.Mark/Grade secured in eachsubject in 10th BoardExamination

Maximum Mark Total Mark Secured English Mathematics Science Social Science Grade

600 409 60 60 58 63 B2

Have you secured above markin your Annual HSE(O)examination ?

Yes

b.Have you passed 10th BoardExam Compartmentally ?

No

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

Option College Name Stream Compulsory Electives4th Electives inorder

of preferenceHostelOption

FIRSTChandra Sekhar (Junior) College,Champua

ScienceMIL Oriya Physics,Chemistry,BiologyMathematics,GeologyYes

SECONDRimuli (Junior) College, Rimuli ScienceMIL Oriya Physics,Chemistry,BiologyMathematics No

THIRDJhumpura Panchayat Samiti (Junior)

College, JhumpuraScienceMIL Oriya Physics,Chemistry,BiologyMathematics Yes