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Scholarship Application Form

ST&SC and MBC Welfare Department
Academic Year 2023-24
STSC92311153431012
Government of Odisha

Basic Information

Department Scheme Academic Year Application Type

ST&SC and MBC Welfare Post Matric Scholarship 2023-24 Renew in Same Course
Department

Applicant Details

Applicant Name Category Applicant Gender

RAJESH KUMAR ROUT OBC/SEBC Male

Religion Date of Birth Aadhaar No.

Hindu 12 Jun 1998 (25 Year) XXXXXXXX8734
 Applicant's Aadhaar is seeded with his/her Bank Account and status is Active.

Mobile No. Alternative Mobile No. e-Mail Id

9040218369 9040218369 rajeshrout8369@gmail.com

Father's Name Father Educational Status Father Occupational Status

Abhimanyu Rout Not literate Agriculture

Mother's Name Mother Educational Status Mother Occupational Status

Manjulata Rout Not literate House Wife

Guardian Name Individual/ Family Information

VIEW
-- Beneficiary of NFSA

Address Information

District Block/ULB GP/Ward

Bhadrak Bonth Ganijang

Village Pin Code Address

Hasinpur 756114 HASINPUR GANIJANG BONTH BHADRAK
756114

Educational Qualification Details

For : Matric-Annual

Passing Total Secured Percentage Marksheet/

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

X BSE, 054CB109 2014 600 458 76.33 Uploaded

Odisha

Polytechnic/ SCTE&VT F14002001073 2017 3750 2829 75.44 Uploaded

Diploma

Institute / Course Information (Current Education Information)

Institute Type
Pvt. Unaided

Institute District Block/ULB

Khurdha Bhubaneswar

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NM Institute of Engineering and Technology,

Bhubaneswar

Nature of Course Course Branch/Stream/Trade

Self Financing Engineering - B.Tech Course Computer Science & Engineering

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

3rd Year 2221288041 13 Oct 2023

Enrollment No. Enrollment Date

53462 13 Oct 2023

Any Exam Conducted during current academic year? : Yes

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

4th Semester/Periodic 100 73 73.00

Residential Status

Whether
Day Scholar

Details of Last Exam Passed

Course Course Year Passing Year

Engineering - B.Tech Course 2nd Year 2023

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

100 73 73.0

Certificate
Uploaded

Eligibility Information

Income Certificate No. Family Income (in Rs.) To Whom the Certificate Issued
E-INC/2023/1966321   40000.00 MANJULATA ROUT

Issuing Authority Issue Date Income Certificate

Revenue Officers not below the rank of 02 Oct 2023 Uploaded
Tahasildar / Additional Tahasildar

Matriculation Certificate No. Issuing Authority Matriculation Certificate

347462 BSE, Odisha (Annual) Uploaded

Caste Certificate No. To Whom the Certificate Issued Issuing Authority

E-SEB/2022/1171442  RAJESH KUMAR ROUT Revenue Officers not below the rank of
Tahasildar / Additional Tahasildar

Issue Date Caste Certificate

09 Sep 2022 Uploaded

Institute Declaration Certificate

NA

Bank Information

Account Holder Name IFSC Code Account No.

RAJESH KUMAR ROUT PUNB0093920 0939010195546

Whether account number tagged /seeded with

the Aadhaar number?
Yes

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Bank Name Branch Name

PUNJAB NATIONAL BANK BARAPADA

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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