Scholarship Application Form
ST&SC and MBC Welfare Department
Academic Year 2021-22
STSC9211008765427
Government of Odisha
Basic Information
Department Scheme Academic Year Application Type
ST&SC and MBC Welfare Post Matric Scholarship 2021-22 Renew in Same Course
Department
Applicant Details
Applicant Name Category Applicant Gender
Deepak Swain OBC/SEBC Male
Religion Date of Birth Aadhaar No.
Hindu 04 Nov 2002 XXXXXXXX8626
Mobile No. Alternate Mobile No. e-Mail Id
7847878909 9556355668 swain50d@[Link]
Father's Name Father Educational Status Father Occupational Status
Gopabandhu Swain Literate Agriculture
Mother's Name Mother Educational Status Mother Occupational Status
Santilata Swain Not literate House Wife
Guardian Name Individual/ Family Information
VIEW
Gopabandhu Swain Beneficiary of NFSA
Address Information
District Block/ULB GP/Ward
Puri Pipili Dhandamakundapur
Village Pin Code Address
Karimula 752104 AT-BAITANGI
PO-DANDAMUKUNDAPUR
PS-
PIPILI
DIST-PURI
PIN-752104
ODISHA
Educational Qualification Details
For : Matric-Annual
Course Board Roll No. Passing Year Total Mark/CGPA Secured Marks/CGPA Percentage (%) Certificate
X BSE, Odisha 067BA0046 2018 600 450 75.00 Uploaded
Plus 2 CHSE, Odisha 320MC183 2020 600 476 79.33 Uploaded
Institute / Course Information (Current Education Information)
Institute District Block/ULB
Gandhi Institute for Technology(GIFT) Khurdha Khordha
Course Branch/Stream/Trade Course Year (Current Year of Study)
Engineering - [Link] Course Electronics and Communications Engineering 2nd Year
Admission/Registration No. Admission/Readmission Date Enrollment No.
2001298272 02 Jul 2021 2001298272
Enrollment Date
01 Dec 2020
Any Exam Conducted during current academic year? : Yes
Exam Type Total Mark/CGPA Secured Mark/CGPA Percentage (%)
1st Semester/Periodic 10 7.83 74.39
Residential Status
Whether
Day Scholar
Details of Last Exam Passed
Course Course Year Passing Year
Engineering - [Link] Course 1st Year 2021
Total Mark/CGPA Secured Marks/CGPA Percentage (%)
10 7.83 74.39
Certificate
Uploaded
Eligibility Information
Income Certificate No. Family Income To Whom the Certificate Issued
E-INC/2020/635265 62000.00 GOPABANDHU SWAIN
Issuing Authority Issue Date Income Certificate
Revenue Officers not below the rank of 18 Nov 2020 Uploaded
Tahasildar / Additional Tahasildar
Matriculation Certificate No. Issuing Authority Matriculation Certificate
1801109473 BSE, Odisha (Annual) Uploaded
Caste Certificate No. To Whom the Certificate Issued Issuing Authority
E-SEB/2021/344354 DEEPAK SWAIN Revenue Officers not below the rank of
Tahasildar / Additional Tahasildar
Issue Date Caste Certificate
25 Oct 2021 Uploaded
Bank Information
Account Holder Name IFSC Code Account No.
DEEPAK SWAIN SBIN0009628 34228632418
Whether account number tagged /seeded with Bank Name Branch Name
the Aadhaar number? STATE BANK OF INDIA DANDAMUKUNDAPUR
Yes
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