Common Application Form 25D085349
For Admission into Degree Course (2025-26)
Higher Education Department, Government of Odisha
Applicant Copy
+3
Monday, Jun 23, 2025 02:58:36 AM
Passed Appeared
1 +2 Council Name of the Examination Board
Details COUNCIL OF HIGHER SECONDARY EDUCATION, ODISHA
(As in admit
Card) Year of Passing/Appeared Exam Type Roll Number
2023 Annual 322CA201
Applicant's
2 ARPITA SUMAN
Name
3 Father's Name HARIHAR JALLY
4 Mother's Name PRATIVA JALLY
Blood Group Gender Religion Date of Birth
B+ FEMALE HINDUISM 23 Jan 2005
Mother
Nationality Aadhaar No. Parent Mobile No.
Tongue
INDIAN ODIA ********0491 9861207202
5 Personal Details Child without biological or adoptive parents No Orphan No
Staying at Child Care Institutions No Green Passage No
HIV/AIDS-Affected Family (either father, Single Mother
No No
mother, or both) Family
Not Yet Registered for
Apaar ID Reason
APAAR ID
6. Permanent Address
a. State ODISHA b. District CUTTACK c. Block / ULB CUTTACK SADAR
d. Address QR NO-LB-29, VIGILANCE COLONY, MAHANADI VIHAR, CUTTACK-4 e. PIN Code 753004
f. Whatsapp No. 8455014820 g. Mobile No. 8455014820
h. e-Mail [email protected]
7. Reservation Details
a. Schedule Tribe No Schedule Caste Yes Other Backward Class No Socially and Educationally Backward Class No General No
b. Persons with Disabilities No
c. Ex-Service Man No Serving Defence Personnel No Children of Martyrs No
Do you have odisha domicile(Resident)
Yes
Certificate?
8. Weightage Details
a. NCC b. NSS Camp
NCC-B No NCC No International No National No State Level(Issued by No Best NSS No
Certificate (CAMP/COURSE/ACTIVITIES) Level Level State NSS Cell) Volunteer Award
c. Rover & Ranger d. Sports & Games
President Recognition(PR) No Rajya Puraskar(RP) No International Level No National Level No State Level No
9. Details of Mark Secured in +2 or equivalent Examination
a. Stream Science
b. Mark secured in each subject in +2 or Maximum Mark Total Mark Secured English MIL Chemistry Mathematics Biology
equivalent Examination
600 448 55 71 76 0 89
c. Have you studied Odia at HSC/+2 Level or No
Higher (or Passed Odia as a special Exam
from BSE Odisha in 10th Standard)?
d. Have you passed +2 or equivalent Exam No
Compartmentally / Instant?
10. Income Details of Parents
Mother's HOME Actual Income of the Parents
a. Father's Occupation GOVT.SERVICE b. c. 1200000
Occupation MAKER (Together)in Rs.
d. Annual Income of the Parents (Together)in Rs. Above 8,00,000
e. Do your parents pay income tax? Yes
11 Bank Information
a. Account Number 10603216693 b. IFSC Number SBIN0009029
d. Bank Name STATE BANK OF INDIA e. Branch Name LINK ROAD, CUTTACK
f. Name of Account Holder HARIHAR JALLY
Other Information
a. Special Category NONE OF THESE
Are your parents
Are your parents beneficiaries of the CM-KISAN beneficiaries of the
b. No c. No
scheme? Nirman Shramik
Kalyan Yojana?
Are you willing to participate in skilling courses
Future Career Option
d. under NASSCOM/Infosys Springboard/Swayam No e. DOCTOR
Desired by Applicant
portal/ Coursera?
12 Record of educational institution last attended
Name of the Location of the
a. CUTTACK - J.K.B.K JR. GOVT. COLLEGE b. CUTTACK
School/College School/College
c. District CUTTACK d. Year of Joining 2021
e. Year of Leaving 2023
13 Option(s)/Choice(s) Details
Option University/College Course type Major-I/Three Major- Minor-I Minor-II Hostel Admission
Preference Minors II Option Fee
1st RAVENSHAW SINGLE MAJOR PHYSICAL -- BIOLOGICAL BIOLOGICAL NO 2250.00
UNIVERSITY,CUTTACK WITH TWO SCIENCE- SCIENCE- SCIENCE-
MINORS COMPUTER ZOOLOGY BOTANY
SCIENCE
2nd SHAILABALA WOMEN'S SINGLE MAJOR SELF FINANCING- -- BIOLOGICAL BIOLOGICAL NO 12338.00
(AUTONOMOUS) COLLEGE, WITH TWO COMPUTER SCIENCE- SCIENCE-
CUTTACK MINORS SCIENCE ZOOLOGY BOTANY
3rd CHRIST (DEGREE) COLLEGE, SINGLE MAJOR SELF FINANCING- -- BIOLOGICAL BIOLOGICAL NO 35507.00
CUTTACK WITH TWO COMPUTER SCIENCE- SCIENCE-
MINORS SCIENCE ZOOLOGY BOTANY
4th STEWART SCIENCE (DEGREE) SINGLE MAJOR PHYSICAL -- BIOLOGICAL BIOLOGICAL NO 22732.00
COLLEGE, CUTTACK WITH TWO SCIENCE- SCIENCE- SCIENCE-
MINORS COMPUTER ZOOLOGY BOTANY
SCIENCE
5th JATIYA KABI BIRA KISHORE SINGLE MAJOR BIOLOGICAL -- BIOLOGICAL PHYSICAL NO 2635.00
GOVERNMENT (DEGREE) COLLEGE, WITH TWO SCIENCE-BOTANY SCIENCE- SCIENCE-
CUTTACK MINORS ZOOLOGY CHEMISTRY
The admission fee may vary at the time of admission.
During filling up the CAF, applicants will have the option to select their course type:
(i) Single Major with two Minors, (ii) Double Major, or (iii) Three Minors.
However, the selection will be done only for the Major-I subjects based on the applicants' preferred choices.
UNDERTAKING
I do hereby agree to abide by the rules of the College/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 college is found not satisfactory, my name will automatically be
removed from the college. 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 college 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 (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 Higher Secondary (+2) Mark Sheets-cum-Provisional Certificate (or equivalent Board). If an applicant has not received the mark sheet from the board
in-time, then the downloaded mark sheet from Internet, duly endorsed by the leaving School/College Principal will be admissible.
3 Self signed (on the front side) color passport size photograph (1 Copy) to be affixed in the CAF.
4 Schedule Tribe/ Schedule Caste/ Other Backward Class certificates from revenue officer not below rank of Tahasildar/Additional Tahasildar.
