Scholarship Application Form

ST&SC and MBC Welfare Department

Academic Year 2023-24
STSC92312153623681
Government of Odisha

Basic Information

Department Scheme Academic Year Application Type

ST&SC and MBC Welfare Post Matric Scholarship 2023-24 New
Department

Applicant Details

Applicant Name Category Applicant Gender

Kamal Lochan Mohanta OBC/SEBC Male

Religion Date of Birth Aadhaar No.

Hindu 27 Feb 2008 (15 Year) XXXXXXXX3399
 Applicant's Aadhaar is seeded with his/her Bank Account and status is Active.

Mobile No. Alternative Mobile No. e-Mail Id

7978268225 7855074320 kamallochan854@gmail.com

Father's Name Father Educational Status Father Occupational Status

Kotin Kumar Mohanta Literate Unemployed

Mother's Name Mother Educational Status Mother Occupational Status

Sabita Mohanta Not literate House Wife

Guardian Name Individual/ Family Information

VIEW
Kotin Kumar Mohanta Beneficiary of NFSA

Address Information

District Block/ULB GP/Ward

Mayurbhanj Baripada Rajabasa

Village Pin Code Address

Chandua 757107 chandua, Rajabasa, Baripada, Mayurbhanj,
757107

Educational Qualification Details

For : Matric-Annual

Passing Total Secured Percentage Marksheet/

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

X CBSE, New 12172388 2023 500 400 80.00 Uploaded

Delhi

Institute / Course Information (Current Education Information)

Institute Type
Govt.

Institute District Block/ULB

ODISHA ADARSHA Mayurbhanj Baripada
VIDYALAYA,RANIBHOL,BARIPADA

Nature of Course Course Branch/Stream/Trade

General Plus 2 Science
Course Year (Current Year of Study) Admission/Registration No. Admission/Readmission Date
1st Year 315 26 Apr 2018

Enrollment No. Enrollment Date

315 26 Apr 2018

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 2023 500

Secured Marks/CGPA Percentage (%) Certificate

400 80.0 Uploaded

Eligibility Information

Income Certificate No. Family Income (in Rs.) To Whom the Certificate Issued
E-INC/2022/655219   60000.00 Kotin Kumar mohanta

Issuing Authority Issue Date Income Certificate

Revenue Officers not below the rank of 29 Jun 2022 Uploaded
Tahasildar / Additional Tahasildar

Matriculation Certificate No. Issuing Authority Matriculation Certificate

12172388 CBSE, New Delhi Uploaded

Caste Certificate No. To Whom the Certificate Issued Issuing Authority

E-OBC/2023/387234  Kamal lochan mohanta Revenue Officers not below the rank of
Tahasildar / Additional Tahasildar

Issue Date Caste Certificate

08 Aug 2023 Uploaded

Institute Declaration Certificate

NA

Bank Information

Account Holder Name IFSC Code Account No.

KAMAL LOCHAN MOHANTA BKID0005507 550710110011362

Whether account number tagged /seeded with

the Aadhaar number?
Yes

Bank Name Branch Name

BANK OF INDIA BADABRAHMANAMARA

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