Scholarship Application Form

ST&SC and MBC Welfare Depart ment

Academic Year 2022-23
STSC12212112466737
Government of Odisha

Basic Informat ion

Department Scheme Academic Year Application Type

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

Applicant Det ails

Applicant Name Category Applicant Gender

JAGABANDHU SAHOO OBC/SEBC Male

Religion Date of Birth Aadhaar No.

Hindu 25 Dec 2007 (15 Year) XXXXXXXX6930

 Applicant's Aadhaar is seeded with his/her Bank Account and status is Active.

Mobile No. Alternative Mobile No. e-Mail Id

8984565445 6370029808 sahoojagabandhu947@gmail.com

Father's Name Father Educational Status Father Occupational Status

Batakrushna Sahoo Literate Self-Employed/ Business

Mother's Name Mother Educational Status Mother Occupational Status

Rina Sahoo Literate House Wife

Guardian Name
--

Address Informat ion

District Block/ULB GP/Ward

Jajpur Korei Tarakot

Village Pin Code Address

Tarakote 755025 AT/PO- TARAKOTE PS-KORAI DIST-JAJPUR

Inst it ut e / Course Informat ion (Current Educat ion Informat ion)

Institute Type
Govt.

Institute District Block/ULB

RAGHUNATH SAHOO NODAL HIGH SCHOOL Jajpur Korei

Course Admission/Readmission No. Admission/Readmission Date

X 2113080410100263 08 Apr 2019

Any Exam Conducted during current academic year? : No

Resident ial St at us

Whether
Day Scholar

Det ails of Last Exam Passed

Course Passing Year Total Mark/CGPA

IX 2022 600
Secured Marks Percentage (%)
450 75.0

Eligibilit y Informat ion

Income Certificate No. Family Income (in Rs.) To Whom the Certificate Issued
E-INC/2021/872086   65000.00 BATAKRUSHNA SAHOO

Issuing Authority Issue Date Income Certificate

Revenue Officers not below the rank of 05 Oct 2021 Uploaded
Tahasildar / Additional Tahasildar

Caste Certificate No. To Whom the Certificate Issued Issuing Authority

E-OBC//2021/276957  JAGABANDHU SAHOO Revenue Officers not below the rank of
Tahasildar / Additional Tahasildar

Issue Date Caste Certificate

29 Sep 2021 Uploaded

Bank Informat ion

Account Holder Name IFSC Code Account No.

JAGABANDHU SAHOO BARB0JAJPUR 29808100010565

Whether account number tagged /seeded with

the Aadhaar number?
Yes

Bank Name Branch Name

BANK OF BARODA JAJPUR ROAD

Passbook front page

Uploaded

PFMS Account Det ails

Account holder name Account no. Bank name

JAGABANDHU SAHOO 040110058110 India Post Payments Bank
 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