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Name : Father's Name : KHATURAM JHANKAR Mother's Name : GITANJALI JHANKAR Date of Birth : 16/10/1994 Gender : Permanent Address Correspondence Address Category : Religion : Male ST Hindu Contact Numbers : AT/PO-JORABAGAVIA/PS-BELPAHAR, DISTRICT :- Jharsuguda , STATE :- Odisha , PIN CODE :- 768217 AT/PO-JORABAGAVIA/PS-BELPAHAR, DISTRICT :- Jharsuguda , STATE :- Odisha , PIN CODE :- 768217 8018125130 Email Address : karuna.jhankar@gmail. com KARUNA JHANKAR Special Category : No Institute : Tehsil / District : Course : Diploma / Electrical Third Year Academic Year : Annual Income : Rs.40000/- Padmashree krutartha Aya Instt. of Eng. Tech. Bargarh /Bargarh (Baragarh) 2014 - 15 Hosteller : No 10th Class Details: Orissa State Board /2009-10 /07mf109 Enrolment No. and Date : Admission date for Academic year(2014 - 15) : 27/08/2012 Personal Details Academic Details Contact Details : Bank Details : Bank Name : Branch Address: Branch Name : Account Number : PUNJAB NATIONAL BANK Baragarh, BARGARH Ambika Complex, Baragarh, 768028 4020001500021919 Declaration I, KARUNA JHANKAR S/o KHATURAM JHANKAR hereby declare that the information given in the application form are true as per best of my knowledge and belief. I also undertake that if, at any stage, it is found to the satisfaction of the sanctioning authority that the information given by me is false, the entire amount of scholarship will be recovered from as arrears of land revenue or any other law in force apart from such penal action as warranted by law. I have not applied for /in receipt of any other scholarship from Govt of India/Govt of Orissa. Check List Document to be attached : - 1. Caste Certificate issued from the competent authority 2. Residential Certificate 3. Income Certificate from the concerned authorized authority/Persons 4. H.S.C Certificate (Photo Copy) Attested by Competent authority 5. Photo Copy of the first page of Bank Passbook having account no 6. Income declaration of parents/guardian from all the sources on non-judicial stamp paper (Signature) ADHAAR Card No. : Not Availabl Hostel Admission Date: Last Exam Percentage: N.A. 61.00 Caste Certificate No. & Date : IFSC Code : 6511/2014 & 19/06/2014 Caste Certficate Issued by : TAHASILDAR 250 & 27/08/2012 PUNB0402000 Generated by Scholarship Portal as on 20/8/2014 Government of Odisha State Scholarship Portal Scholarship Application Form Application Number : 345352 Scheme : Post Matric Scholarship-ST Renewal Application

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Page 1: Applicant Form

Name :

Father's Name : KHATURAM JHANKAR Mother's Name : GITANJALI JHANKAR

Date of Birth : 16/10/1994

Gender :

Permanent Address

Correspondence Address

Category : Religion :

Male

ST Hindu

Contact Numbers :

AT/PO-JORABAGAVIA/PS-BELPAHAR, DISTRICT :- Jharsuguda , STATE :- Odisha , PIN CODE :- 768217

AT/PO-JORABAGAVIA/PS-BELPAHAR, DISTRICT :- Jharsuguda , STATE :- Odisha , PIN CODE :- 768217

8018125130 Email Address : [email protected]

KARUNA JHANKAR

Special Category : No

Institute : Tehsil / District :

Course : Diploma / Electrical Third Year Academic Year :

Annual Income : Rs.40000/-

Padmashree krutartha Aya Instt. of Eng. Tech.

Bargarh /Bargarh (Baragarh)

2014 - 15

Hosteller : No 10th Class Details: Orissa State Board /2009-10 /07mf109

Enrolment No. and Date :

Admission date forAcademic year(2014 - 15) :

27/08/2012

Personal Details

Academic Details

Contact Details :

Bank Details :

Bank Name :

Branch Address:

Branch Name :

Account Number :

PUNJAB NATIONAL BANK Baragarh, BARGARH

Ambika Complex, Baragarh, 768028 4020001500021919

Declaration

I, KARUNA JHANKAR S/o KHATURAM JHANKAR hereby declare that the information given in the application form are true as per best of my knowledge and belief. I also undertake that if, at any stage, it is found to the satisfaction of the sanctioning authority that the information given by me is false, the entire amount of scholarship will be recovered from as arrears of land revenue or any other law in force apart from such penal action as warranted by law. I have not applied for /in receipt of any other scholarship from Govt of India/Govt of Orissa.

Check ListDocument to be attached : -

1. Caste Certificate issued from the competent authority2. Residential Certificate3. Income Certificate from the concerned authorized authority/Persons4. H.S.C Certificate (Photo Copy) Attested  by Competent authority5. Photo Copy of the first page of Bank  Passbook  having account no6. Income declaration of parents/guardian from all the sources on non-judicial stamp paper

(Signature)

ADHAAR Card No. : Not Availabl

Hostel Admission Date:

Last Exam Percentage:

N.A. 61.00

Caste Certificate No. & Date :

IFSC Code :

6511/2014 & 19/06/2014 Caste Certficate Issued by :

TAHASILDAR

250 & 27/08/2012

PUNB0402000

Generated by Scholarship Portal as on 20/8/2014

Government of OdishaState Scholarship Portal

Scholarship Application Form

Application Number : 345352

Scheme : Post Matric Scholarship-STRenewal Application

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