Common Application Form
for Admission into Government & Private ITIs (2025-26)
Skill Development and Techincal Education Department, Government of Odisha 25T0009039
Tuesday, 15-Jul-2025 7:40:03 PM
1 Qualification 10th Pass
Name of the Examination Board Year of Passing Exam Type Roll Number
2 10th Board Details Board of Secondary Education, 2025 Annual 069bb0255
Odisha, Cuttack-753001
3 Applicant's Name Akash Panda
4 Father's Name Baren Kumar Panda
5 Mother's Name Reena Ratha
Sex Religion Date of Birth
6 Personal Details
MALE HINDU 10 Nov 2009
7. Highest Qualification None
8. Resident Address
a. State ODISHA b. District KHURDA c. Block / ULB BHUBANESWAR
d. Address SCR80KHARAVELNAGAR,UNIT 3,BHUBANESWAR e. PIN Code 751001
f. Telephone No. g. Mobile No. 8480618298 h. e-Mail [email protected]
Aadhaar Card
i. Whatsapp No. 8480618298 j. XXXXXXXX7672 k. Ration Card No. NA
No.
9. Bank Details
a. Name of Bank Bank of Baroda b. Branch Name BHUBANESHWAR c. Account No. 78300100016079
Account
d. IFSC Code BARB0VJBHUB e. AKASH PANDA
Holder Name
10. Reservation Details
a. Schedule Tribe (ST) No Schedule Caste (SC) No OBC/SEBC No General(Unreserved) Yes
Persons with Disability
b. No Sports No Minority No
(PwD)
PVTG (Particularly vulnerable
c. Ex-Service Man (ESM) No None
tribal group)
d. Whether Parent working in any Government/PSU/Defense sector in Odisha : No
e. Whether parent belongs to Building and construction worker No
f. Do you belong to Economically Weaker Sections (EWS) category ? No
g. Are you interested for seat sponsored by OMC? No OMC Village Name NA
11. Income Details of Parents
Are you an orphan ? No
Annual Income of the Parents
a. Father's Occupation BUSINESS b. Mother's Occupation HOME MAKER c. 0-1,00,000
(Together) in Rs.
d. Income Certificate Number NA
12.Details of Mark/Grade Secured in Examination
Total Mark English Math Science Social Science Grade
Total Mark Secured Maximum Secured Maximum Secured Maximum Secured Maximum Secured Secured
600 271 100 43 100 34 100 48 100 41 D
b. Have you passed 10th Board Exam Compartmentally ? No
Payment Details
Mode of Payment Payment Status Amount Paid Transaction No.
Online SUCCESS 100 BIC5FXZ0KRR0F1
13 Option(s)/Choice(s) Details
Option Institute Name Trade Hostel Option IMC / REGULAR
1st ITI Bhubaneswar, Khurda - Bhubaneswar (MC) Food Production (General) (NSQF) No REGULAR
2nd ITI Bhubaneswar, Khurda - Bhubaneswar (MC) Multimedia Animation and Special Effects (NSQF) No REGULAR
3rd ITI Bhubaneswar, Khurda - Bhubaneswar (MC) Refrigeration & Air Conditioning Technician(NSQF) No REGULAR
4th ITI Bhubaneswar, Khurda - Bhubaneswar (MC) Electrician (NSQF) No REGULAR
5th ITI Bhubaneswar, Khurda - Bhubaneswar (MC) Computer Operator and Programming Assistant (NSQF) No REGULAR
UNDERTAKING
I do hereby agree to abide by the rules of the Institue /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 Institue is found not satisfactory, my name will automatically be removed from the Institue . I undertake that
information furnished by me in this application is true and correct and i undertake that any wrong information furnished by me, detected afterwards will be treated as cognizable offence.
I further undertake that I will not involve in any ragging activities in the Institue and hostel premises. I understand that criminal case will be filed against me if I indulged 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 be 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).
HSC Mark Sheets-cum-Provisional Certificate (or equivalent Board). / Electronic print copy from BSE Odisha website if the original has not been issued by BSE Odisha for
2
2025.
3 Original School / College Leaving Certifcate. / Undertaking for BSE(O)-2025 passed out students, if SLC/CLC has not been issued by the institutions.
4 Attested copy of the Bank Pass Book showing name of the account holder,account number, IFSC number or Letter from Bank Manager on the above information.
5 Attested copy of Income Certificate of parents from the employer / appropriate authority (not below the rank of Tahasildar / Additional Tahasildar) .
