12/20/22, 10:59 PM STSC92212201809081

Scholarship Application Form

ST&SC and MBC Welfare Department
Academic Year 2022-23
STSC92212201809081
Government of Odisha

Basic Information

Department Scheme Academic Year Application Type

ST&SC and MBC Welfare Post Matric Scholarship 2022-23 New
Department

Applicant Details

Applicant Name Category Applicant Gender

Debasis Sahoo OBC/SEBC Male

Religion Date of Birth Aadhaar No.

Hindu 12 Aug 2003 (19 Year) XXXXXXXX5741

Mobile No. Alternative Mobile No. e-Mail Id

9777680257 9777680257 debasissahoo548@gmail.com

Father's Name Father Educational Status Father Occupational Status

Nirakar Sahoo Literate Self-Employed/ Business

Mother's Name Mother Educational Status Mother Occupational Status

Khirodini Sahoo Literate House Wife

Guardian Name
--

Address Information

District Block/ULB GP/Ward

Keonjhar Harichadanpur Harichandanpur

Village Pin Code Address

Harichandanpur 758028 At-Harichandanpur, PS/PO-Harichandanpur
DIST-Keonjhar, Odisha

Educational Qualification Details

For : Matric-Annual

Passing Total Secured Percentage Marksheet/

Course Board Roll No. Year Mark/CGPA Marks/CGPA (%) Certificate

X BSE, Odisha 464CC0012 2018 600 480 80.00 Uploaded

Plus 2 CHSE, 344MA050 2020 600 385 64.17 Uploaded

Odisha

Institute / Course Information (Current Education Information)

Institute District Block/ULB

Udayanath (Autonomous) College of Cuttack Kantapada
Science & Technology, Adaspur

Nature of Course Course Branch/Stream/Trade

Self Financing Plus 3 Computer Science

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

3rd Year 2002010420350209 02 Aug 2022

Enrollment No. Enrollment Date

BS20-523 24 Nov 2020

Any Exam Conducted during current academic year? : Yes

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

3rd Semester/Periodic 500 253 50.60

Residential Status

Whether
Day Scholar

Details of Last Exam Passed

Course Course Year Passing Year

Plus 3 2nd Year 2022

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

500 253 50.6

Certificate
Uploaded

Eligibility Information

Income Certificate No. Family Income To Whom the Certificate Issued

E-INC/2022/1370272   55000.00 NIRAKAR SAHOO

Issuing Authority Issue Date Income Certificate

Revenue Officers not below the rank of 09 Nov 2022 Uploaded
Tahasildar / Additional Tahasildar

Matriculation Certificate No. Issuing Authority Matriculation Certificate

1801470681 BSE, Odisha (Annual) Uploaded

Caste Certificate No. To Whom the Certificate Issued Issuing Authority

E-OBC/2020/175262  DEBASIS SAHOO Revenue Officers not below the rank of
Tahasildar / Additional Tahasildar

Issue Date Caste Certificate

08 Feb 2021 Uploaded

Bank Information

Account Holder Name IFSC Code Account No.

DEBASIS SAHOO SURY0BK0000 221060002145

Whether account number tagged /seeded with

the Aadhaar number?
Yes

Bank Name Branch Name

Suryoday Small Finance Bank CHIKILI

Passbook front page

Uploaded

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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

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