Scholarship Application Form

ST&SC and MBC Welfare Department

Academic Year 2022-23
STSC92211212235190
Government of Odisha

Basic Information

Department Scheme Academic Year Application Type

ST&SC and MBC Welfare Post Matric Scholarship 2022-23 Renew in Same Course
Department

Applicant Details

Applicant Name Category Applicant Gender

Pramod Kumar Jena OBC/SEBC Male

Religion Date of Birth Aadhaar No.

Hindu 25 Jul 2001 XXXXXXXX3074

Mobile No. Alternative Mobile No. e-Mail Id

7608030428 7608030428 pjena9955@gmail.com

Father's Name Father Educational Status Father Occupational Status

Shambhunath Jena Literate Agriculture

Mother's Name Mother Educational Status Mother Occupational Status

Chhabismita Jena Literate House Wife

Guardian Name
Shambhunath Jena

Address Information

District Block/ULB GP/Ward

Balasore Baleshwar Rasulpur

Village Pin Code Address

Manudiha 756029 AT-MANUDIHA PO-KUSHADIHA PS-BASTA
DIST-BALASORE PIN-756029 STATE-ODISHA

Educational Qualification Details

For : Matric-Annual

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

X BSE, Odisha 075CA0036 2017 600 456 76.00 Uploaded

Plus 2 CHSE, Odisha 391AA049 2019 600 450 75.00 Uploaded

Institute / Course Information (Current Education Information)

Institute District Block/ULB

KMBB College of Engineering and Technology, Khurdha Khordha
Khurda (Engineering)

Nature of Course Course Branch/Stream/Trade

General Engineering - B.Tech Course Mechanical Engineering

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

4th Year 1901329093 01 Jul 2022

Enrollment No. Enrollment Date

1901329093 11 Aug 2019
Any Exam Conducted during current academic year? : Yes

Exam Type Total Mark/CGPA Secured Mark/CGPA Percentage (%)

5th Semester/Periodic 10 7.77 73.82

Residential Status

Whether
Hosteller

Date of Admission in Hostel Hostel Details No. of Months

01 Jul 2021 Residing in institution run hostel within 10
institution campus

Residential Certificate
Uploaded

Details of Last Exam Passed

Course Course Year Passing Year

Engineering - B.Tech Course 3rd Year 2022

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

10 7.77 73.82

Certificate
Uploaded

Eligibility Information

Income Certificate No. Family Income To Whom the Certificate Issued

E-INC/2022/1161146   60000.00 SHAMBHUNATH JENA

Issuing Authority Issue Date Income Certificate

Revenue Officers not below the rank of 06 Oct 2022 Uploaded
Tahasildar / Additional Tahasildar

Matriculation Certificate No. Issuing Authority Matriculation Certificate

1701180288 BSE, Odisha (Annual) Uploaded

Caste Certificate No. To Whom the Certificate Issued Issuing Authority

E-SEB/2022/307562  PRAMOD KUMAR JENA Revenue Officers not below the rank of
Tahasildar / Additional Tahasildar

Issue Date Caste Certificate

14 Oct 2022 Uploaded

Divyang Disability Percentage Issuing Authority

NA -- --

Issue Date Special Category Certificate

NA

Bank Information

Account Holder Name IFSC Code Account No.

PRAMOD JENA SBIN0006413 35258960069

Whether account number tagged /seeded with the

Aadhaar number?
Yes

Bank Name Branch Name

STATE BANK OF INDIA SRIRAMPUR

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