Scholarship Application Form

ST&SC and MBC Welfare Department

Academic Year 2022-23
STSC92211302346115
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

CHANDRAKANTA BARIK OBC/SEBC Male

Religion Date of Birth Aadhaar No.

Hindu 14 Dec 1999 XXXXXXXX9117

Mobile No. Alternative Mobile No. e-Mail Id

7204848571 7735269536 chandrakantbarik2020@gmail.com

Father's Name Father Educational Status Father Occupational Status

Ajay Kumar Barik Literate Agriculture

Mother's Name Mother Educational Status Mother Occupational Status

Sabitri Barik Literate House Wife

Guardian Name
Ajay Kumar Barik

Address Information

District Block/ULB GP/Ward

Bhadrak Basudevpur Lunga

Village Pin Code Address

Lunga 756124 S/O-AJAY KUMAR BARIK, AT/PO-LUNGA,VIA-
ERTAL,PS-BASUDEVPUR,DIST-BHADRAK,PIN-
756124,ODISHA

Educational Qualification Details

For : Matric-Annual

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

X BSE, Odisha 150CB017 2015 600 458 76.33 Uploaded

Plus 2 CHSE, Odisha 101AB050 2021 600 435 72.50 Uploaded

Institute / Course Information (Current Education Information)

Institute District Block/ULB

Atal Bihari (Degree) College, Basudevpur Bhadrak Basudebpur Mpl

Nature of Course Course Branch/Stream/Trade

General Plus 3 Arts

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

2nd Year BA21-018 03 Aug 2022
Enrollment No. Enrollment Date
BA21-018 13 Sep 2021

Any Exam Conducted during current academic year? : No

Residential Status

Whether
Day Scholar

Details of Last Exam Passed

Course Course Year Passing Year

Plus 2 2nd Year 2021

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

600 435 72.5

Certificate
Uploaded

Eligibility Information

Income Certificate No. Family Income To Whom the Certificate Issued

E-INC/2021/678375   40000.00 Ajay kumar barik

Issuing Authority Issue Date Income Certificate

Revenue Officers not below the rank of 02 Sep 2021 Uploaded
Tahasildar / Additional Tahasildar

Matriculation Certificate No. Issuing Authority Matriculation Certificate

1501205588 BSE, Odisha (Annual) Uploaded

Caste Certificate No. To Whom the Certificate Issued Issuing Authority

E-OBC/2021/231306  Chandrakanta barik Revenue Officers not below the rank of
Tahasildar / Additional Tahasildar

Issue Date Caste Certificate

19 Sep 2021 Uploaded

Bank Information

Account Holder Name IFSC Code Account No.

CHANDRAKANTA BARIK SBIN0002014 35564282608

Whether account number tagged /seeded with

the Aadhaar number?
Yes

Bank Name Branch Name

STATE BANK OF INDIA BASUDEVPUR

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