Scholarship Application Form

ST&SC and MBC Welfare Department

Academic Year 2021-22
STSC9211017648978
Government of Odisha

Basic Information

Department Scheme Academic Year Application Type

ST&SC and MBC Welfare Post Matric Scholarship 2021-22 Renew in New Course
Department

Applicant Details

Applicant Name Category Applicant Gender

Rasmiranjan Das SC Male

Religion Date of Birth Aadhaar No.

Hindu 01 Nov 2004 XXXXXXXX6878

Mobile No. Alternate Mobile No. e-Mail Id

6372763548 8658746710 facebookakashwww@gmail.com

Father's Name Father Educational Status Father Occupational Status

Subal Chandra Das Literate Agriculture

Mother's Name Mother Educational Status Mother Occupational Status

Sasmita Das Not literate House Wife

Guardian Name Individual/ Family Information

VIEW
-- Beneficiary of NFSA

Address Information

District Block/ULB GP/Ward

Balasore Baleshwar Baincha

Village Pin Code Address

Totapal Samil Palabalasore 756003 At-Palabalasore, Po-Ghodapada,ps-Sadar

Educational Qualification Details

For : Matric-Annual

Course Board Roll No. Passing Year Total Mark/CGPA Secured Marks/CGPA Percentage (%) Certificate

X BSE, Odisha 194CA0089 2020 600 319 53.17 Uploaded

Institute / Course Information (Current Education Information)

Institute District Block/ULB

Fakir Mohan Higher Secondary School, Balasore Baleshwar Mpl
Balasore

Course Branch/Stream/Trade Course Year (Current Year of Study)

Plus 2 Arts 2nd Year

Admission/Registration No. Admission/Readmission Date Enrollment No.

IA20-181 14 Jul 2021 IA20-181

Enrollment Date
23 Sep 2020

Any Exam Conducted during current academic year? : No

Residential Status

Whether
Day Scholar

Details of Last Exam Passed

Course Passing Year Total Mark/CGPA

X 2020 600

Secured Marks/CGPA Percentage (%) Certificate

319 53.17 Uploaded

Eligibility Information

Income Certificate No. Family Income To Whom the Certificate Issued

E-INC/2020/756669   62000.00 SUBAL CHANDRA DAS

Issuing Authority Issue Date Income Certificate

Balasore, BALESHWAR 11 Jan 2021 Uploaded

Matriculation Certificate No. Issuing Authority Matriculation Certificate

201164915 BSE, Odisha (Annual) Uploaded

Caste Certificate No. To Whom the Certificate Issued Issuing Authority

E-SCO/2020/246824  RASMIRANJAN DAS Balasore Tehsil, BALESHWAR District

Issue Date Caste Certificate

30 Jan 2021 Uploaded

Bank Information

Account Holder Name IFSC Code Account No.

Rasmi Ranjan Das SBIN0007980 37091997048

Whether account number tagged /seeded with Bank Name Branch Name
the Aadhaar number? STATE BANK OF INDIA SORO
Yes

Passbook front page

Uploaded
 Student Declaration

1. I have read and understood the conditions of award of Scholarship.

2. I am aware that my application is liable to be rejected, if it is found at any stage, that Aadhaar number provided by me is wrong or Aadhaar number is of
someone’s else.
3. I am aware that if more than one application is found, all my applications are liable to be rejected.
4. I am aware that for any wrong entry or mis-match of the Bank-account details, the State Government will not be responsible for mis-credit and I will be
held responsible for diversion of public money on this ground.

Date ........................

Place ........................ Full Signature of Applicant