Scholarship Application Form

School & Mass Education Department

Academic Year 2022-23
SME542212072366961
Government of Odisha

Basic Information

Department Scheme Academic Year Application Type

School & Mass Education Junior Merit (Class - 11 to 12) 2022-23 New
Department

Unique Ref. No. (CAF Barcode)

NA

Applicant Details

Applicant Name Category Applicant Gender

Lakshajit Naik ST Male

Religion Date of Birth Aadhaar No.

Hindu 04 Jun 2005 XXXXXXXX1233

Mobile No. Alternative Mobile No. e-Mail Id

7853998214 7381648301 lakshajitn@gmail.com

Father's Name Mother's Name Guardian Name

Balaram Naik Saraswati Naik --

Address Information

District Block/ULB GP/Ward

Mayurbhanj Bisoi Nuagan

Village Pin Code Address

Nuagan 757033 VIL-NUAGAN,GP-NUAGAN
POST-NUAGAN
PO-
BISOI
BLOCK-BISOI
PIN-757033

Educational Qualification Details

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

X CBSE, New Delhi 12120863 2021 500 303 60.60 Uploaded

Institute / Course Information (Current Education Information)

Institute District Block/ULB

O.A.V,SAHARPADA Keonjhar Saharapada

Nature of Course Course Branch/Stream/Trade

General Plus 2 Science

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

2nd Year 036 22 Mar 2021

Details of Last Exam Passed

Course Passing Year Total Mark/CGPA

X 2021 500

Secured Marks/CGPA Percentage (%) Certificate

303 60.6 Uploaded

Eligibility Information

Income Certificate No. Family Income To Whom the Certificate Issued

E-INC/2021/265726   70000.00 BALARAM NAIK

Issuing Authority Issue Date Income Certificate

Revenue Officers not below the rank of 17 Jun 2021 Uploaded
Tahasildar / Additional Tahasildar

Residence Certificate No. To Whom the Certificate Issued Issuing Authority

E-RES/2021/329523  LAKSHAJIT NAIK Revenue Officers not below the rank of
Tahasildar / Additional Tahasildar

Issue Date Residence Certificate

21 Jun 2021 Uploaded

Regd. No. on College ID Card College ID Card Cover Page

036 Uploaded

Bank Information

Account Holder Name IFSC Code Account No.

LAKSHYAJIT NAIK BKID0005412 541210510005571

Whether account number tagged /seeded with

the Aadhaar number?
No

Bank Name Branch Name

BANK OF INDIA SAHARPADA

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