Scholarship Application Form

ST&SC and MBC Welfare Department

Academic Year 2021-22
STSC9211008765427
Government of Odisha

Basic Information

Department Scheme Academic Year Application Type

ST&SC and MBC Welfare Post Matric Scholarship 2021-22 Renew in Same Course
Department

Applicant Details

Applicant Name Category Applicant Gender

Deepak Swain OBC/SEBC Male

Religion Date of Birth Aadhaar No.

Hindu 04 Nov 2002 XXXXXXXX8626

Mobile No. Alternate Mobile No. e-Mail Id

7847878909 9556355668 swain50d@gmail.com

Father's Name Father Educational Status Father Occupational Status

Gopabandhu Swain Literate Agriculture

Mother's Name Mother Educational Status Mother Occupational Status

Santilata Swain Not literate House Wife

Guardian Name Individual/ Family Information

VIEW
Gopabandhu Swain Beneficiary of NFSA

Address Information

District Block/ULB GP/Ward

Puri Pipili Dhandamakundapur

Village Pin Code Address

Karimula 752104 AT-BAITANGI
PO-DANDAMUKUNDAPUR
PS-
PIPILI
DIST-PURI
PIN-752104
ODISHA

Educational Qualification Details

For : Matric-Annual

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

X BSE, Odisha 067BA0046 2018 600 450 75.00 Uploaded

Plus 2 CHSE, Odisha 320MC183 2020 600 476 79.33 Uploaded

Institute / Course Information (Current Education Information)

Institute District Block/ULB

Gandhi Institute for Technology(GIFT) Khurdha Khordha

Course Branch/Stream/Trade Course Year (Current Year of Study)

Engineering - B.Tech Course Electronics and Communications Engineering 2nd Year

Admission/Registration No. Admission/Readmission Date Enrollment No.

2001298272 02 Jul 2021 2001298272
Enrollment Date
01 Dec 2020

Any Exam Conducted during current academic year? : Yes

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

1st Semester/Periodic 10 7.83 74.39

Residential Status

Whether
Day Scholar

Details of Last Exam Passed

Course Course Year Passing Year

Engineering - B.Tech Course 1st Year 2021

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

10 7.83 74.39

Certificate
Uploaded

Eligibility Information

Income Certificate No. Family Income To Whom the Certificate Issued

E-INC/2020/635265   62000.00 GOPABANDHU SWAIN

Issuing Authority Issue Date Income Certificate

Revenue Officers not below the rank of 18 Nov 2020 Uploaded
Tahasildar / Additional Tahasildar

Matriculation Certificate No. Issuing Authority Matriculation Certificate

1801109473 BSE, Odisha (Annual) Uploaded

Caste Certificate No. To Whom the Certificate Issued Issuing Authority

E-SEB/2021/344354  DEEPAK SWAIN Revenue Officers not below the rank of
Tahasildar / Additional Tahasildar

Issue Date Caste Certificate

25 Oct 2021 Uploaded

Bank Information

Account Holder Name IFSC Code Account No.

DEEPAK SWAIN SBIN0009628 34228632418

Whether account number tagged /seeded with Bank Name Branch Name
the Aadhaar number? STATE BANK OF INDIA DANDAMUKUNDAPUR
Yes

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