Personal

Last Exam Passed

Name: SUBHAM KUMAR PATEL

Last Exam Passed: +3 (Graduation)

Email: subham1794@gmail.com

Stream: Science

Mobile: 8018196504

Name of Board/Council/University:
SAMBALPUR UNIVERSITY,Jyot

Category: OBC
Religion: Hindu
Date of Birth: 1994-05-15

Name of College/Institution:
GOVERMENT AUTONOMOUS
COLLEGE,ROURKELA

Sex: Male

Address of College/Institution:
AT/PO-PANPOSH(ROURKELA),DISSUNDARGARH,PIN-769004

Nationality: INDIAND

Year of Entry: 2012

Mother Tongue: Odia

Year of Passing: 2015

AadharCard Id (Optional): -

Mark Type: MARKS

Voter Id Card (Optional): -

Mark/CGPA Secured: 1130

Max Mark / CGPA: 1800
Percentage: 65.38

Present Course & University /

College/ Institution Information

Applied Scholarship information

Scholarship Type: 3 Year MCA

College Name: COLLEGE OF IT AND

MANAGEMENT EDUCATION,
BHUBANESWAR

Scholarship Scheme:
PROFESSIONAL/TECHNICAL

Course Name: Technical & Professional

Name of Entrance: OJEE

Date of Admission: 2015-08-05

Roll No.: 3052831011

Course duration (in Year): 3

All India Rank: 170

Roll No.: 1505107024

Year of Exam: 2015

Parents / Guardian Information:

Father / Guardian Name: HIMANSU
KUMAR PATEL

Permanent Address
State: Odisha
District: SUNDARGARH

Father's Profession: FARMER

Block/ULB: BALISANKARA
Father's Annual Income (in Rs.): 76000
House No./ Street/ Village: KINJIRKELA
Mother's Name: BABITA PATEL
Post Office: KINJIRKELA
Mother's Profession: HOUSEWIFE
Pin Code: 770015
Mother's Annual Income (in Rs.): 0

Bank Account
Account Number: 3133000100098941
Account Holder Name: SUBHAM KUMAR
PATEL

A/C Type: Personal

IFSC Number: PUNB0313300

Bank Name: Punjab National Bank

MICR Number: 770024001

Bank Address: SUNDARGARH,ODISHA

(For online money transfer through RTGS/NEFT)

Declaration

I do hereby declare that the above information furnished by me is true and correct to the best of
my knowledge and belief. I am not availing any scholarship from Government of Odisha in any
other.

Date _________________ Place

_______________

Full Signature of Applicant

Studentship Certificate by the Head of the Institution

Certified that Shri/Ms./Smt. _________________________ has been admitted this institute on
_____________ as a regular student of the course ______________________________
during the academic session ______________________ bearing Roll
No.____________________ His / Her rank in the Entrance Test conducted by
_________________________________________ is ________________________ On the
basis of which he/she has been admitted into this institution.

Date ________________________

Full Signature of Head of the Institution

with date & Seal

Essential Enclosures
The following documents needs to be submitted at the college/institution along with this
form
Slno

Documents

Self-Attested copy of Residential Certificate.

Self-Attested copy of income certificate of

parents from employer and /or appropriate
authority.

Self-Attested copy of certificate & mark sheet

of last qualifying examination.

Self Attested copy of the first page of Bank

Pass-Book showing name of the applicant &
account number.

Self-Attested copy of rank card issued by the

chairperson of OJEE/ALL India Test

Self-Attested copy of Aadhar Card / Voter Id

Card (if available with the student)

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