Name of the Candidate
Name of the Degree (please specify)
UG  
PG  M.phil   Others  
Name of the College / D.D.E., Centre code
Register Number
Month & Year of Passing the final year examination
Sex Male    Female   
Email I.D. if any
Address to which the certificate is to be sent.
(Address should be in bold letters with pincode)
Fee Remittance Particulars
Name of the Bank place 
Chalan Date  
Draft No. & Date  
Amount paid in Rs.  
PLEASE INDICATE YOUR GRIEVANCE (MARK) FOR SEMESTER
Non-receipt of Statement of Marks   Non-receipt of Consolidated Statement of Marks   Non-receipt of Provisional Certificate  Non-receipt of Migration Certificate   Non-receipt of Duplicate Statement of Marks &
Consolidated Statement of Marks 
PLEASE INDICATE YOUR GRIEVANCE (MARK) FOR BOTH SEMESTER AND NON-SEMESTER
Non-receipt of Degree Certificates   Non-receipt of Genuineness Certificate   Non-receipt of Duplicate Degree Certificate   Non-receipt of Official Transcripts   Non-receipt of Medium of Instructions Certificate 
 

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