Scholarship Application Form

ST&SC and MBC Welfare Depart ment

Academic Year 2022-23
STSC92212282621297
Government of Odisha

Basic Informat ion

Department Scheme Academic Year Application Type

ST &SC and MBC Welfare Post Mat ric Scholarship 2022-23 Renew in New Course
Depart ment

Applicant Det ails

Applicant Name Category Applicant Gender

SONALI SWAIN OBC/SEBC Female

Religion Date of Birth Aadhaar No.

Hindu 07 Feb 2002 (20 Year) XXXXXXXX3176

Mobile No. Alternative Mobile No. e-Mail Id

9937336824 6371982059 sonaliswain353@gmail.com

Father's Name Father Educational Status Father Occupational Status

Sunildut t a Swain Lit erat e Self-Employed/ Business

Mother's Name Mother Educational Status Mother Occupational Status

Pravat i Swain Lit erat e House Wife

Guardian Name
--

Address Informat ion

District Block/ULB GP/Ward

Jajpur Jajpur Similia

Village Pin Code Address

Chit ahat a 755009 At -Chit ahat a, Po-Badabant a, Ps-Jajpur
Sadar

Educat ional Qualificat ion Det ails

For : Mat ric-Annual

Passing Total Secured Percentage Marksheet/

Course Board Roll No. Year Mark/CGPA Marks/CGPA (%) Certificate

X BSE, Odisha 334AD0063 2017 600 455 75.83 Uploaded

Plus 2 CHSE, Odisha 377CC027 2019 600 456 76.00 Uploaded

Plus 3 Ramadevi Womens UGS19PHY404 2022 2600 2224 85.54 Uploaded

University,Bhubaneswar

Inst it ut e / Course Informat ion (Current Educat ion Informat ion)

Institute District Block/ULB

Udayanat h (Aut onomous) College of Cut t ack Kant apada
Science & Technology, Adaspur

Nature of Course Course Branch/Stream/Trade

Self Financing M. Sc. Physics

Course Year (Current Year of Study) Admission/Registration No. Admission/Readmission Date

1st Year 10 18 Nov 2022

Enrollment No. Enrollment Date

10 18 Nov 2022

Any Exam Conducted during current academic year? : No

Resident ial St at us

Whether
Host eller

Date of Admission in Hostel Hostel Details No. of Months

08 Dec 2022 Residing in inst it ut ion run host el wit hin 10
inst it ut ion campus

Hosteller Bonafide Certificate

Uploaded

Det ails of Last Exam Passed

Course Course Year Passing Year

Plus 3 3rd Year 2022

Total Mark/CGPA Secured Marks/CGPA Percentage (%)

2600 2224 85.54

Certificate
Uploaded

Eligibilit y Informat ion

Income Certificate No. Family Income To Whom the Certificate Issued

E-INC/2022/1519375   60000.00 JYOT IKANTA BHUJABAL

Issuing Authority Issue Date Income Certificate

Revenue Officers not below t he rank of 12 Dec 2022 Uploaded
Tahasildar / Addit ional Tahasildar

Matriculation Certificate No. Issuing Authority Matriculation Certificate

1701081944 BSE, Odisha (Annual) Uploaded

Caste Certificate No. To Whom the Certificate Issued Issuing Authority

e-SEB/2017/743  LAXMI KANTA MISHRA Revenue Officers not below t he rank of
Tahasildar / Addit ional Tahasildar

Issue Date Caste Certificate

26 May 2017 Uploaded

Institute Declaration Certificate

NA

Divyang Disability Percentage Issuing Authority

NA -- --

Issue Date Special Category Certificate

NA

Bank Informat ion

Account Holder Name IFSC Code Account No.

SONALI SWAIN PUNB0675400 6754001700033086

Whether account number tagged /seeded with

Whether account number tagged /seeded with
the Aadhaar number?
No

Bank Name Branch Name

PUNJAB NAT IONAL BANK JAJPUR T OWN

Passbook front page

Uploaded
 St udent Declarat ion

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