kalinga Bharati

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1. Name ( in Block letters )

2. Name of Father / Guardian

3. Occupation of Father / Guardian with occupation / office address

Name

C/O

Plot No.

Lane

P.O.

Dist.

Pin Code

Phone

Mobile

E-mail

4. Address for Correspondence

Name

C/O

Plot No.

Lane

P.O.

Dist.

Pin Code

Phone

Mobile

E-mail

5. Permanent Address

Name

C/O

Plot No.

Lane

P.O.

Dist.

Pin Code

Phone

Mobile

E-mail

6. Date of Birth

7. Sex ( Please Tick )

Male Female

8. Mother Tongue

9. Educational Qualification

Exam Passed	Board / University	Year of Passing	Division / Class	Full Marks	Total Marks Secured	% of Marks Secured*	Subjects taught
Class X or equivalent
Any other Qualification

10. Compulsory Subjects

i English
ii Physics
iii Chemistry

11. Choice of Subjects

MIL ( please tick one )

Oriya Alternative

Third Optional

Mathematics Biology

Fourth Optional

Mathematics Biology Electronics

Vocational Subject

IT                 Laboratory   Computer
                                Technician          Language
                                Course

12. Name and Address of School /College last Attended from which SLC / CLC is to be submitted for admission.

The College is under the University / Board of

I here by under take that the information given above is true to the best of my knowledge and belief.

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