Name of the Father / Spouse: Date of Birth ( As recorded in the HSC Pass Certificate) : Sex : Caste (UR /ST/ SC/ SEBC) : Permanent Address: : Present address for correspondence ( in block letters) : Whether passed Odia as a subject (Yes/No) : Mark to be given in the following Proforma : Full / Total Secured Marks Marks (Excluding 4th (Excluding Name of the Name of the Percentage of Optional for 4th Optional Examination Institution Mark X & XII for X & XII examinations examinations Only) Only) 1 HSC/Equivalent 2 +2 Science examination under CHSE Odisha/Equivalent 3 Specific technical qualification Full Signature of the candidate DECLARATION I do hereby declare that all the information furnished in the application form are true to the best of my knowledge and belief. Any wrong calculation of mark/percentage/false mark sheet or any wrong information, if detected during verification or in future, my application shall be treated as cancelled. Full Signature of the candidate
Name of the Father / Spouse: Date of Birth ( As recorded in the HSC Pass Certificate) : Sex : Caste (UR /ST/ SC/ SEBC) : Permanent Address: : Present address for correspondence ( in block letters) : Whether passed Odia as a subject (Yes/No) : Mark to be given in the following Proforma : Name of the Examination Name of the Institution Full / Total Marks (Excluding 4th Optional for X & XII examinations Only) Secured Marks (Excluding 4th Optional for X & XII examinations Only) Percentage of Mark 1 HSC/Equivalent 2 +2 Science examination under CHSE Odisha/Equivalent 3 Specific technical qualification Full Signature of the candidate DECLARATION I do hereby declare that all the information furnished in the application form are true to the best of my knowledge and belief. Any wrong calculation of mark/percentage/false mark sheet or any wrong information, if detected during verification or in future, my application shall be treated as cancelled. Full Signature of the candidate