Application for Scholarship

[e-Medhabruti 2018-19] 18S003153  

Higher Education Department, Government of Odisha

Office Copy  
  1. Scholarship Information

Scholarship Type  TECHNICAL/PROFESSIONAL

  2. Applicant Information

District PURI Institute Name COLLEGE OF PHARMACEUTICAL SCIENCE,PURI Admission Date 06 NOV 2018

Applicant Name JAGANNATH MOHAPATRA Gender MALE

Course Name B.PHARMA (BACHELOR IN PHARMACY) Subject Name PHARMACY

PH/OH NO Roll No. 102 Category GENERAL

Religion HINDU Date of Birth 01 NOV 2000 Nationality INDIAN

Mother Tongue ORIYA Mobile No. 8457925933 Aadhaar No. 936564480609

 3. Parent / Guardian Information

  Name Profession Annual Income (in Rs.)
Parent/Guardian PRUTHURAJ MOHAPATRA PRIVATE SECTOR SERVICE 96000.00

Mother DIPTIMAYEE MOHAPATRA HOME MAKER 0.00

 4. Permanent Address

State  ODISHA District  ANGUL Block/ ULB ANGUL (MPL)

House No., Street/Village,Post Office, Police Station KHEMKA CLOTH STORE,DURGA SHANKAR ROAD,ANGUL

PIN Code  759122 Telephone No. 845-7925933 Email JAGANNATHMOHAPATRA2000@GMAIL.COM

 5. Examinations Information

Mark/CGPA Max.
Name of the Examination Name of Board / Council/University Year of Passing Mark Type
Secured Mark/CGPA
HIGHER SECONDARY CERTIFICATE
CHSE, ODISHA 2018 MARK 432 600
EXAMINATION /+2

 6. Bank Account Information of the applicant (Only Nationalised Bank Account may be given for electronic transfer of Scholarship)

Beneficiary Name JAGANNATH MOHAPATRA

Account Number 05790110097670
IFSC Number UCBA0000579
MICR Code
Bank Name
(For online money transfer through RTGS/NEFT) UCO BANK

Branch Name ANGUL

Telephone Number

Page 1 of 2

DECLARATION

1- I, hereby, declare that the entries made by me in the Application Form are correct and true to the best of my knowledge.
2- I, hereby, undertake to present the original documents at the time of online validation made by the concerned authorities of the College/Higher Education Department.
3- I, have not received any scholarship for the current year from the State / Central Government .Further, I do hereby undertake that in case I will get any other
scholarship from Central government or any State government ,I will refund the medhabruti amount which has been received by me.
4- I, further declare that, my scholarship may be cancelled, at any stage, if I am found ineligible and/or the information provided by me are found to be incorrect and legal
action may be initiated against me for submission of wrong data/ hiding of information as per law.

Date ____________ Full Signature of Applicant

I do here by fully endorse the undertaking made by the student.

Date ____________ Full signature of the Head of the Institution with date & seal.
 
 
Essential Enclosures
  Sl# Documents
Attested copy of Resident Certificate (Certificate to be issued by the competent authority i.e. from the concerned Tehsildar / Addl. Tehsildar. If parents are
  1 working under Government of Odisha; can produce resident proof from the employer).

  2 Attested copy of Income Certificate of parents from the competent authority i.e. Revenue Officer not below the rank of Tehsildar / Addl. Tehsildar.

  3 Attested copy of ceritificate & marksheet of last qualifying examination.

Attested copy of the Bank Pass Book showing name of the account holder,account number, IFSC number or Letter from Bank Manager on the above
  4
information.

Page 2 of 2
 Application for Scholarship
[e-Medhabruti 2018-19]
Higher Education Department, Government of Odisha  

Applicant Copy   18S003153  

   
 
Date of Submission Signature of the Receiving Official

  1. Scholarship Information

Scholarship Type  TECHNICAL/PROFESSIONAL

  2. Applicant Information

District PURI College Name COLLEGE OF PHARMACEUTICAL SCIENCE,PURI Admission Date 06 NOV 2018

Applicant Name JAGANNATH MOHAPATRA Gender MALE

Course Name B.PHARMA (BACHELOR IN PHARMACY) Subject Name PHARMACY

PH/OH NO Roll No. 102 Category GENERAL

Religion  HINDU Date of Birth  01 NOV 2000 Nationality   INDIAN

Mother Tongue  ORIYA Mobile No. 8457925933 Aadhaar No. 936564480609

 3. Parent / Guardian Information

  Name Profession Annual Income (in Rs.)
Parent/Guardian PRUTHURAJ MOHAPATRA PRIVATE SECTOR SERVICE 96000.00

Mother DIPTIMAYEE MOHAPATRA HOME MAKER 0.00

 4. Permanent Address

State  ODISHA District  ANGUL Block/ ULB ANGUL (MPL)

House No., Street/Village,Post Office, Police Station KHEMKA CLOTH STORE,DURGA SHANKAR ROAD,ANGUL

PIN Code  759122 Telephone No. 845-7925933 Email JAGANNATHMOHAPATRA2000@GMAIL.COM

 5. Examinations Information

Mark/CGPA Max.
Name of the Examination Name of Board / Council/University Year of Passing Mark Type
Secured Mark/CGPA
HIGHER SECONDARY CERTIFICATE
CHSE, ODISHA 2018 MARK 432 600
EXAMINATION /+2

 6. Bank Account Information of the applicant (Only Nationalised Bank Account may be given for electronic transfer of Scholarship)

Beneficiary Name JAGANNATH MOHAPATRA

Account Number 05790110097670
IFSC Number UCBA0000579
MICR Code
Bank Name
(For online money transfer through RTGS/NEFT) UCO BANK

Branch Name ANGUL

Telephone Number