PRERANA Odisha Common Integrated Application Form For Post Matric Scholarships To ST/SC/OBC/SEBC Students : mpsc.mp.nic.in

Organization : ST & SC Development & Minorities & Backward Classes Welfare Department
Service Name : Common Integrated Application Form for Post-Matric Scholarships to ST/SC/OBC-SEBC Students of Odisha
Applicable For : SC/ST/OBC Students
Applicable State : Odisha
Website : http://scholarshipportal.mp.nic.in/Index.aspx
Application Form : https://www.scholarships.net.in/uploads/17433-Form.pdf

CIAF Scholarships Form :

Common Integrated Application Form for Post-Matric Scholarships to ST/SC/OBC-SEBC Students of Odisha

Related / Similar Scholarship :
Prerana Odisha Post Matric Scholarship SC/ST/OBC Students Registration

Application Format :
Fresh: / Renewal: [Put a tick (v) mark in the box for whichever is applicable]

Affix a Passport size photograph with his/ her signature thereon and attested by the Head of the Institution.

Basic Details:
1. Name in full (in Block letters) :
2. Father’s Name: Shri.
3. Mother’s Name: Smt.
4. Gender: Male/ Female
5. Date of Birth (DD/MM/YYYY) :
6. Category (SC/ST/OBC/SEBC):
7.Religion (Hindu / Christian/ Muslim ) :
8. Special Category (Blind/ Hearing Impairment/ Leprosy cured/ Mentally retarded/ Severely Handicapped/ Locomotors disabled) :
9. Mobile No. :
10. e-Mail Id:
11. Adhar Card (UID) No.:

Address Details:
12. Address for Correspondence:
District:
Pin Code:
State:

13. Permanent Address:
District:
Pin Code:
State:

Institute Details:
14. Name of the Institute :
15. Tehsil:
16.District:
17.State:

Scheme Related Details:
18. Academic Year:

Application Details :
19. Course Name:
20. Branch Name:
21. Course Year:
22. Admission Date(DD/MM/YYYY) :
23. Enrollment No.:
24. Enrollment Date:
25. Percentage of Marks obtained in last Examination:

10th Class Passing Details:
26. Board Name:
27. Year of Passing (YYYY):
28. Board Roll Number:

Eligibility Details :
29. Total Annual Income (Family) in:
30. Day Scholar/ Hosteller: 31. Hostel Admission Date:
32. Caste Certificate Number: 33. Caste Certificate Date:
34. Caste Certificate Issuing Authority:

Bank Account Details (for Electronic Transfer of Funds):
35. IFSC Code of the Bank:

If not available
Name of the Bank :
Branch Name :

36. Bank Account Number :

Declaration:
I, _____________________________ S/o / D/o/ W/o/ C/o __________________________ hereby declare that the information given in the application form is true as per 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 me, apart from such penal action as warranted by law.

Date :
Place :
(Signature)

Note: All fields are mandatory except e-mail address.

Declaration by the Institute:
(To be filled up by the Head of the School/ College/ Institute where the applicant is studying)

1. Certified that the information filled in by Shri/Kumari/Smt. ___________________ S/o/D/o/W/o/C/o Shri_________________________________________ who is admitted in ________________________ _________________ course for the academic Session _______ in _________________________________ ___________ school/college/institute is correct.

2. Certified that this institute is affiliated to ___________________________________ University/ Board and is recognized by the Government of India/ State Government of _______________.

3. Details of the non-refundable compulsory course fee(excluding hostel rent and other incidental charges)

Particulars of non-refundable compulsory fees-Amount payable to the Institution :
1. Tuition:
2. Examination:
3. Games:
4. Library:
5. Medical:
6. Others:
Total :

4. Details of bank account of school/college/institute (For deposit of course fee):
IFSC Code of the Bank :

If not available
Name of the Bank :
Branch Name :
Bank Account Number :

It is also certified that the student has not changed the course of study and/or the school/ college/ institute of the study for which the scholarship was originally awarded /has changed the course of study and/or school/college/ institute with prior approval of the State Government (please strike out which is not applicable).

Date:
Place:

Signature of Head of the school/college/institute with official seal

Note:
Documents to be enclosed with the application:
1. Proof of permanent residence
2. Caste Certificate
3. Mark Sheet of last examination(Self Certified)
4. Income Certificate
5. Passport size photo with signature
6. Photo copy of bank passbook (for a/c no. with IFSC Code)
7. Attested photo copy of Mark sheet of last examination passed.