Scholarship Application Form

ST&SC and MBC Welfare Depart ment

Academic Year 2023-24
STSC92401093553259
Government of Odisha

Basic Informat ion

Department Scheme Academic Year Application Type

ST &SC and MBC Welfare Post Mat ric Scholarship 2023-24 New
Depart ment

Applicant Det ails

Applicant Name Category Applicant Gender

Sat ya Prakash Barik OBC/SEBC Male

Religion Date of Birth Aadhaar No.

Hindu 22 Nov 2007 (16 Year) XXXXXXXX6038
 Applicant's Aadhaar is seeded with his/her Bank Account and status is Active.

Mobile No. Alternative Mobile No. e-Mail Id

9692483624 9692483624 bariksanjayakumar740@gmail.com

Father's Name Father Educational Status Father Occupational Status

Kapileswar Barik Lit erat e Agricult ure

Mother's Name Mother Educational Status Mother Occupational Status

Sat yabhama Barik Not lit erat e House Wife

Guardian Name Individual/ Family Information

VIEW
Kapileswar Barik Beneficiary of NFSA

Address Informat ion

District Block/ULB GP/Ward

Keonjhar Hat adihi Danar

Village Pin Code Address

Chasakhanda 756121 AT- CHASAKHANDA PO- DANAR DIST-
KEONJHAR

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, 134CC0045 2023 600 494 82.33 Uploaded

Odisha

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

Institute Type
Govt . Aided
Institute District Block/ULB
Naami Higher Secondary School, Naami Bhadrak Bhandaripokhari

Nature of Course Course Branch/Stream/Trade

General Plus 2 Art s

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

1st Year IA23001 07 Jul 2023

Enrollment No. Enrollment Date

IA23001 07 Jul 2023

Any Exam Conducted during current academic year? : No

Resident ial St at us

Whether
Day Scholar

Det ails of Last Exam Passed

Course Passing Year Total Mark/CGPA

X 2023 600

Secured Marks/CGPA Percentage (%) Certificate

494 82.33 Uploaded

Eligibilit y Informat ion

Income Certificate No. Family Income (in Rs.) To Whom the Certificate Issued
E-INC/2022/1232660   60000.00 KAPILESWAR BARIK

Issuing Authority Issue Date Income Certificate

Revenue Officers not below t he rank of 10 Oct 2022 Uploaded
Tahasildar / Addit ional Tahasildar

Matriculation Certificate No. Issuing Authority Matriculation Certificate

233233307 BSE, Odisha (Annual) Uploaded

Caste Certificate No. To Whom the Certificate Issued Issuing Authority

E-SEB/2023/458467  SAT YA PRAKASH BARIK Revenue Officers not below t he rank of
Tahasildar / Addit ional Tahasildar

Issue Date Caste Certificate

15 Sep 2023 Uploaded

Institute Declaration Certificate

NA

Bank Informat ion

Account Holder Name IFSC Code Account No.

SAT YA PRAKASH BARIK IOBA0ROGB01 203034002003776

Whether account number tagged /seeded with

the Aadhaar number?
No

Bank Name Branch Name

ODISHA GRAMYA BANK SALANIA

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