PERSONAL DETAILS
Name Jeeban Pradeep Surname Agnihotry
Email ID jaganagnihotry@gmail.com Gender Male
Mobile Number 9178391414 Telephone Number
Date of birth 08/03/2005 Place of Birth Jajapur
Religion Hindu Mother Tongue Odia
Nationality India Disability
ADDRESS DETAILS
Current Address Sasanda, Jajpur 755027, Jajapur, Odisha, 755027, India
Permanent Address Sasanda, Jajpur 755027, Jajapur, Odisha, 755027, India
FAMILY DETAILS
No of members in the family 3 Annual Family Income(in Rs.) 41,000.00
No. of children studying in family 1 Are you child of a single parent? No
Are both your parent’s deceased? No
FAMILY MEMBERS
Relationship Name Education Occupation
Father Subash Chandra Agnihotry 12th Grade Farmer
ALTERNATE CONTACT DETAILS
Name Subash Chandra Agnihotry Surname Subash
Mobile Number 9178391414 Email ID agnihotryjagan@gmail.com
Relationship Father Address Sasanda, Jajpur
Pin Code 755027 District Jajapur
State Odisha Country India
SECONDARY EDUCATION
Medium
Passing Max Obtained
Education Board Institute Name Of State City %
Year Marks Marks
Instruction
12th 78
Rc Nodal High
10th 2020 Orissa Board Oriya Odisha Jajapur 600.00 467.00 77.83
School
GRADUATION
Institute Duration Passing Max Obtained
Education Degree Type Degree Program Name/Uni State City (Years) Year Marks Marks
versity
Biju Patnaik
Institute Of
Information
B.Pharm.(Bachelor
UG Pharmacy Technology Odisha Rourkela 4 2026
of Pharmacy) &
Management
Studies
EXTRACURRICULAR ACTIVITIES/ COMMUNITY ENGAGEMENT ACTIVITIES
Activity Type Activity Description Role Responsibilities
No records found
SPECIAL RECOGNITIONS, ACADEMIC HONOURS & AWARDS
Award Name Awarded Year Description
No records found
DOCUMENTS
Document Document Name
Photo ID Proof Course fees 2.pdf
Current Address Proof aadhaar.pdf
Applicant photo PhotoStudio_1666453462519.jpeg
Family income proof income .pdf
Marksheet of 10th Class Board Examination matric certificate .pdf
Marksheet of 12th Class Board Examination 12th mark.pdf
Proof of enrollment in current institution Course fees 2.pdf
By signing my name in the box below:
1. I confirm that all information provided by me in this application is accurate and truthful, and is a wholly accurate and fair
representation of my achievements. I understand that these terms and conditions need to be reviewed and confirmed by my parents
or legal guardian who will indicate their consent by signing their name in the appropriate box below.
2. I understand that any material misrepresentation by me in this application will result in disqualification of my application and,
where appropriate, the rescinding of scholarship.
3. I understand that in case of any communication from Reliance Foundation seeking information or documents, I am required to
respond to the same within 2 working days. Failing to do so may result in disqualification of my application at Reliance Foundations
discretion.
4. I understand that this application and supporting materials will be shared with people involved in the evaluation process and
others who are responsible for administering the Reliance Foundation Scholarship and involved in the selection process and I
hereby voluntarily provide my consent for sharing my personal info with the aforementioned people in order to facilitate my
application for the Reliance Foundation Scholarship program
5. I understand that in case I fail to maintain a satisfactory record, or in case my conduct is considered prejudicial to the best
interest of the program, my award may be withdrawn, and payments terminated.
6. I understand that all Reliance Foundation Scholarships are subject to the policies of Reliance Foundation.
7. I agree that my information may be used for marketing and promotional purposes in the future. In the event I no longer wish for
my information to be used for such purposes, I shall intimate the same to Reliance Foundation
atrf.ugscholarships@reliancefoundation.org.
8. Once submitted, I will no longer have access to any part of the application or supporting materials, including any references or
evaluations.
9. I confirm that as of the date of this application, (i) there have never been any proceedings instituted in respect of an offence
alleged to have been committed by me in any court in India, (ii) no warrant or summons for my appearance has ever been issued
under any law for the time being in force, (iii) no warrant for my arrest has ever been issued by a court under any law for the time
being in force, (iv) no court has ever passed an order prohibiting my departure from India, and (v) I have not, at any time, ever been
convicted by a court in India for any offence under any law.
10. I confirm that I have not (i) been subject to any disciplinary measure, (ii) resigned from a professional or academic appointment,
or (iii) entered into a settlement for, or in connection to, any misconduct, including but not limited to unethical practices,
harassment, sexual harassment or abuse.
Note to Applicant: If you are arrested for, charged with, or convicted of an offence, or any proceedings are instituted or pending
against you, or any warrant or summons issued for your arrest or appearance, or if there is any change in your status or
representations in relation to misconduct after the submission of this application, you must PROMPTLY (within 30 days of the
arrest, charge, misconduct report, etc.) inform the Reliance Foundation Scholarships team at
rf.ugscholarships@reliancefoundation.org
Is this application has been filled on your behalf by someone else No
How did you hear about the Reliance Foundation Scholarships? Web search
In place of your signature, please type your full legal name (applicant)
Date 01/10/2023
