Scholarship Application Form

ST&SC and MBC Welfare Department

Academic Year 2022-23
STSC92211122160306
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 Whether belong to PVTG

Bhagaban Gadaba ST No

PVTG Category Applicant Gender

-- Male

Religion Date of Birth Aadhaar No.

Hindu 05 Apr 2005 (17 Year) XXXXXXXX4383
 Applicant's Aadhaar is seeded with his/her Bank Account and status is Active.

Mobile No. Alternative Mobile No. e-Mail Id

7815000873 7815036535 bgadaba61@gmail.com

Father's Name Father Educational Status Father Occupational Status

Damburu Gadaba Not literate Agriculture

Mother's Name Mother Educational Status Mother Occupational Status

Bhagabati Gadaba Not literate House Wife

Guardian Name Individual/ Family Information

VIEW
-- Beneficiary of NFSA

Address Information

District Block/ULB GP/Ward

Koraput Borigumma B Andiguda

Village Pin Code Address

Bandiguda 764056 AT-BADANAYAKGUDA, PO-KOSAGUDA, PS-
BORIGUMMA

Educational Qualification Details

For : Matric-Annual

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

X BSE, Odisha 164FA0061 2022 600 439 73.17 Uploaded

Institute / Course Information (Current Education Information)

Institute Type
Govt.

Institute District Block/ULB

Vikram Deb Higher Secondary School, Jeypore Koraput Jeypur Mpl

Nature of Course Course Branch/Stream/Trade

General Plus 2 Arts
Course Year (Current Year of Study) Admission/Registration No.4 Admission/Readmission Date
1st Year IA-287 09 Sep 2022

Enrollment No. Enrollment Date

IA-287 09 Sep 2022

Any Exam Conducted during current academic year? : No

Residential Status

Whether
Day Scholar

Details of Last Exam Passed

Course Passing Year Total Mark/CGPA

X 2022 600

Secured Marks/CGPA Percentage (%) Certificate

439 73.17 Uploaded

Eligibility Information

Income Certificate No. Family Income To Whom the Certificate Issued

E-INC/2020/440248   50000.00 DAMBARU GADABA

Issuing Authority Issue Date Income Certificate

Revenue Officers not below the rank of 21 Sep 2020 Uploaded
Tahasildar / Additional Tahasildar

Matriculation Certificate No. Issuing Authority Matriculation Certificate

164FA0061 BSE, Odisha (Annual) Uploaded

Caste Certificate No. To Whom the Certificate Issued Issuing Authority

E-STO/2022/510270  BHAGABAN GADABA Revenue Officers not below the rank of
Tahasildar / Additional Tahasildar

Issue Date Caste Certificate

28 Aug 2022 Uploaded

Institute Declaration Certificate

NA

Bank Information

Account Holder Name IFSC Code Account No.

BHAGABAN GADABA SBIN0002030 38811983736

Whether account number tagged /seeded with

the Aadhaar number?
Yes

Bank Name Branch Name

STATE BANK OF INDIA BORIGUMMA

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