Common Application Form

for Admission into Government & Private ITIs (2024-25)

Cat./Res.:SC
Skill Development and Techincal Education Department, Government of Odisha 24T01648810
Monday, 03-Jun-2024 2:03:44 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 ,

Odisha ,Cuttack-01 (year 2001 & 2018 Annual 039FD0104
onwards)

3 Applicant's Name Nabin Batriya

4 Father's Name Rabi Batriya

5 Mother's Name Susila Batriya

Sex Religion Date of Birth

6 Personal Details
MALE HINDU 12 Sep 2002

7. Highest Qualification 12th

8. Resident Address

a. State ODISHA b. District RAYAGADA c. Block / ULB KOLNARA

d. Address GADISESKHAL,G.SESKHAL,RAYAGADA,ODISHA e. PIN Code 765017

f. Telephone No. g. Mobile No. 6371244727 h. e-Mail [email protected]

Aadhaar Card
i. Whatsapp No. 6371244727 j. XXXXXXXX7234 k. Ration Card No. NA
No.

9. Bank Details

a. Name of Bank State Bank of India b. Branch Name GADISESHAKHAL c. Account No. 36030213610

Account
d. IFSC Code SBIN0017540 e. NABIN BATRIYA
Holder Name

10. Reservation Details

a. Schedule Tribe (ST) No Schedule Caste (SC) Yes OBC/SEBC No General(Unreserved) No

Caste Certificate No. E-CAS/2335OF2018

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 CULTIVATION 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
600 285 100 52 100 30 100 30 100 42 D

b. Have you passed 10th Board Exam Compartmentally ? No

Payment Details
Mode of Payment Payment Status Amount Paid Transaction No.
Online SUCCESS 100 YIC42344080113

13 Option(s)/Choice(s) Details

Option Institute Name Trade Hostel Option IMC / REGULAR

1st ITI Rayagada - Rayagada Fitter (NSQF) Yes REGULAR
2nd ITI Rayagada - Rayagada Electrician (NSQF) Yes REGULAR
3rd ITI Rayagada - Rayagada Machinist (NSQF) Yes REGULAR
4th ITI Rayagada - Rayagada Electronics Mechanic (NSQF) Yes REGULAR
5th ITI Rayagada - Rayagada Welder (NSQF) Yes 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
2024.
3 Schedule Tribe (ST) / Schedule Caste (SC) certificates from revenue officer not below rank of Tahasildar / Additional Tahasildar.
4 Migration Certificate for the applicant from Boards other than BSE, Odisha.
5 Original School / College Leaving Certifcate. / Undertaking for BSE(O)-2024 passed out students, if SLC/CLC has not been issued by the institutions.
6 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.
7 Attested copy of Income Certificate of parents from the employer / appropriate authority (not below the rank of Tahasildar / Additional Tahasildar) .