Scholarship Application Form

Labour & ESI Department

Academic Year 2022-23
LE402302072786997
Government of Odisha

Basic Information

Department Scheme Academic Year Application Type

Labour & ESI Department Nirman Shramik Kalyan Yojana 2022-23 New
(Edn Astt)

Father's Nirman Shramik ID Father's Aadhaar No.

ODMBJ001098090 XXXXXXXX3447

Mothers's Nirman Shramik ID Mothers's Aadhaar No.

-- --

NOTE : Please verify the bottom and get the information in the Nirman Sarmika portal.

Applicant Details

Applicant Name Father's Name Mother's Name

MANAS RANJAN MOHAPATRA BATA KRUSHNA MOHAPATRA Chhabirani Mohapatra

Guardian Name Applicant Gender DDD

Batakrushna Mohapatra Male 25 Sep 2000 (22 Year)

Aadhaar No. Mobile No. e-Mail Id

XXXXXXXX7227 8984202495 manasmrm25@gmail.com

Category Religion
OBC/SEBC Hindu

Beneficiary Details

Father's Registration Date Father's Date of Birth Mother's Registration Date

10 Sep 2018 06 Jul 1964 --

Mother's Date of Birth Nature of Job BPL/Antyodaya Mention Card No.

-- Unskilled Construction Worker --

Child Name
MANAS RANJAN MOHAPATRA

Address Information

District Block/ULB GP/Ward

Mayurbhanj Baripada Mpl Baripada (M) - Ward No.20

Pin Code Address

757001 At-Sungadia, W.No.20, Baripada, Mayurbhanj

Educational Qualification Details

Passing Total Secured Percentage Marksheet/

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

X BSE, Odisha 190CD116 2016 600 552 92.00 Uploaded

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

Plus 2 CHSE, 303MA421 2018 600 485 80.83 Uploaded

Odisha

Institute / Course Information (Current Education Information)

Institute Type
Govt.

Institute District Block/ULB

Veer Surendra Sai Medical College Sambalpur Sambalpur Mc

Nature of Course Course Branch/Stream/Trade

General Medical M.B.B.S.

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

3rd Year 1121PMB080 05 Oct 2022

Details of Last Exam Passed

Course Course Year Passing Year

Medical 3rd Year 2022

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

900 643 71.44

Certificate
Uploaded

Bank Information

Account Holder Name IFSC Code Account No.

BATA KRUSHNA MOHAPATRA BKID0005484 548418210000064

Whether account number tagged /seeded with

the Aadhaar number?
Yes

Bank Name Branch Name

BANK OF INDIA STATION BAZAR BARIPADA

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