23H1044336.pdf

COUNCIL OF HIGHER SECONDARY EDUCATION, ODISHA Form No. 3 (G) EXAMINATION FORM Registration No : EA22A23017...

COUNCIL OF HIGHER SECONDARY EDUCATION, ODISHA Form No. 3 (G) EXAMINATION FORM Registration No : EA22A23017 Year of Registration : 2023 Type of H.S. School / College : College Roll No. : IA23-017 ANNUAL HIGHER SECONDARY EXAMINATION IN ARTS 2025 (REGULAR) (Any correction in the form be signed by the candidate and verifying officer) 1. (a) Name of the Candidate : LOKANATH BARADA (in capital letters) (b) Religion : HINDUISM Mother Tongue : Odia Sex : MALE 2. ( As per 10th (a) Father's Name : SUSANTA BARADA Board Certificate ) (b) Mother's Name : LEJITA BARADA (c) Guardian's Name : (Both Father's and Guardian's names shall be given if the father is not alive) (d) Mobile No. : 9556782115 (e) Annual Income of Father/ Mother /Guardian Rs : 3. Address (a) Permanent : AT-RAJAPUR PO/PS- DIGAPAHANDI (b) Present : AT-RAJAPUR PO/PS- DIGAPAHANDI 4. Date of Birth (in figures) : 15 Mar 2007 (in words) : Fifteen March , Two Thousand Seven 5. (a) Whether the candidate belongs to any of the S.C. / S.T. / S.E.B.C. / O.B.C. / GEN : OBC (b) Physically Disabled : Orthopadic / Visual / Deaf / Dumb : N/A 6. Year of passing the 10th Board Examination : 2023 ANNUAL/SUPPLEMENTARY : (or any equivalent examination) : 7. Name of the H.S. School : Khemundi Higher Secondary School, Digapahandi 8. (a) Category of the Student : Regular / Ex-Regular / Ex-Regular (Compartmental) (b) For Ex-Regular (Compartmental) Candidate (i) Compartmental eligibility year of AHSE : 2022 / 2023 (ii) Paper in which failed in the eligible year : (c) Subjects in which he / she is elegible to be : examined Compulsory Subjects Elective Subjects 1.English 1.Education 3.Political Science 2.MIL Odia 2.History 4.Optional Odia For compartmental candidates, please put "" against the paper(s) in which he/she is eligible to appear and strikeout the rest papers. 9. Language option for writing answers (Except Language Paper(s)) : Odia / English 10. Total amount of fees : Rs. (in words) DECLARATION 1. That the particulars given by me are correct and genuine and CHSE, Odisha shall not be held responsible for any wrong information provided by me. 2. For Ex-Regular Compartmental Candidates: As per Regulation 120 of the Orissa Higher Secondary Education Act and Regulations, 1982, I have filled up forms as a compartmental candidate. I know that I am eligible to appear as a compartmental candidate within two consecutive years following the year in which I became eligible to appear as a compartmental candidate and have to clear all the failed papers at a time. In case of any deviation, I shall be personally held responsible, and the CHSE, Odisha shall not be responsible and binding for any wrong information furnished by me. Signature (in full) of the Candidate Date : P.T.O  CERTIFICATE A. Certified (1) that the particulars given by the candidate are correct (2) that I have verified his / her certificates in original of the qualifying examination and the registration card (3) that his / her conduct has been good and nothing is known against his / her moral character (4) that he / she has studied diligently (5) that the fees prescribed by the Council have been paid by the candidate and deposited to the Council of Higher Secondary Education, Odisha (6) that the form of the Compartmental Candidate has been verified as per Regulation 120 of the Orissa Higher Secondary Education Act and Regulation, 1982 and CHSE shall not be responsible for any lapse of the college authority (7) that the College Authorities will be held responsible for providing any wrong information / data and violation of rules and regulations. Date : Signature of the Verifying Officer Signature of the Principal / Headmaster (with Seal)