6/10/24, 2:43 PM SAMS :: Student Academic Management System

Common Application Form 24H1587076

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

Monday, Jun 10, 2024 02:43:50 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) BSE, ODISHA 2024 Annual 064CB0052

2. Applicant's Name OMPRAKASH MUDULI

3. Father's Name PURNA CHANDRA MUDULI

4. Mother's Name ANUPAMA MUDULI

5. Personal Details Blood Group Gender Religion Date of Birth
B+ MALE HINDUISM 12-Mar-2009
Nationality Mother Tongue Aadhaar No. Guardian Mobile No. Orphan
INDIAN ODIA ********0504 9938755042 No

6. Address for Correspondence

a. State ODISHA b. District BHADRAK c. Block / ULB BONTH

d. Address AT - KUNDALA PO -RANDIAHAT e. PIN Code 756135

Telephone Mobile Whatsapp e-

f. g. 7750022640 h. 7750022640 i. [email protected]
No. No. No. Mail

J. NMMS Awardee No

K. NEET/JEE Details

NEET JEE Other Competitive Exams None Of These

No Yes Yes No

7. Reservation Details
a. Schedule Tribe No Schedule Caste No Other Backward Class Yes 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) Yes 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 Grade
10th Board Examination
600 368 53 45 41 64 B2

b. Have you passed 10th Board Exam No

Compartmentally ?

10. Income Details of Parents

a. Father's Occupation PRIVATE SECTOR SERVICE b. Mother's Occupation NOT APPLICABLE

c. Annual Income of the Parents (Together)in Rs. 1,00,001-2,50,000

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11. Bank Information

a. Account Number 535618210001753 b. IFSC Number BKID0005356

c. MICR Code d. Bank Name BANK OF INDIA

e. Branch Name RANDIA

12. Record of educational institution last attended

a. Name of the School B M BAGURAI NODAL HIGH SCHOOL, BHADRAK b. Location of the School BAGURAI,BHADRAK

c. District BHADRAK d. Year of Joining 2023

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 Bhadrak Higher Science MIL Odia Physics, Chemistry, Mathematics Information Technology No
Secondary School,
Bhadrak

2nd Rameswar Higher Science MIL Odia Physics, Chemistry, Mathematics Information Technology (Voc),Biology No
Secondary School,
Randia

3rd Charampa Higher Science MIL Odia Physics, Chemistry, Mathematics Information Technology No
Secondary School,
Charampa

4th Agarpara Higher Science MIL Odia Physics, Chemistry, Mathematics Information Technology No
Secondary School,
Agarpara

5th Vyasa Nagar Higher Science MIL Odia Physics, Chemistry, Mathematics Information Technology No
Secondary School,
Jajpur Road

Payment Details

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

ONLINE SUCCESS 200.00 ZIC52059727883 10/06/2024

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)
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 NCC Certificate from the competent authority.

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