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Directorate of Distance Learning: Use Blue/Black Ink Only Fill The Form in Block Letters

This document is a degree certificate application form for a distance learning program. It requests information such as the student's name, father's name, course and semester, enrollment number, roll numbers and marks obtained for each semester, as well as contact information including addresses and phone numbers. It notes that a box-sized photograph of the candidate must be attached, and that the student will be charged Rs. 500 for issuance of the degree certificate once completed.

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Sny Kumar Deepak
Copyright
© Attribution Non-Commercial (BY-NC)
Available Formats
Download as PDF, TXT or read online on Scribd
24 views

Directorate of Distance Learning: Use Blue/Black Ink Only Fill The Form in Block Letters

This document is a degree certificate application form for a distance learning program. It requests information such as the student's name, father's name, course and semester, enrollment number, roll numbers and marks obtained for each semester, as well as contact information including addresses and phone numbers. It notes that a box-sized photograph of the candidate must be attached, and that the student will be charged Rs. 500 for issuance of the degree certificate once completed.

Uploaded by

Sny Kumar Deepak
Copyright
© Attribution Non-Commercial (BY-NC)
Available Formats
Download as PDF, TXT or read online on Scribd
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EIILMU/EC/RGB/DCA

DEGREE CERTIFICATE APPLICATION

Directorate of Distance Learning

USE BLUE/BLACK INK ONLY


FILL THE FORM IN BLOCK LETTERS
Paste box - sized photograph of
candidate, duly attested by
Head of the Institution.
Do not use pin or stapler.

Name of the Student

_______________________________

Father's Name

_______________________________

Course & Semester

_______________________________

Enrollment No

______________________________________

Roll No. of 1st Sem/Year _________________ 2nd Sem/Year _________________


3rd Sem/Year _________________ 4th Sem/Year _________________
5th Sem/Year _________________ 6th Sem/Year _________________
7th Sem/Year _________________ 8th Sem/Year _________________
Marks Obtained Out Of Maximum Marks:
1st Sem/Year _________________ 2nd Sem/Year _________________
3rd Sem/Year _________________ 4th Sem/Year _________________
5th Sem/Year _________________ 6th Sem/Year _________________
7th Sem/Year _________________ 8th Sem/Year _________________
(Attested copy of above Marksheets to be submitted alongwith this application)

ECR Code No. / Location

_______________________________________

Total Duration of Course (In years): _______________________________________


POSTAL ADDRESS
OF CANDIDATE

POSTAL ADDRESS
OF ECR LOCATION

PIN CODE
CITY

STATE

PH. No.

PIN CODE

STD CODE

MOB. No.

CITY
PH. No.

E-MAIL

STATE

STD CODE

MOB. No.

E-MAIL

Place: ____________
Date: ____/____/____

Signature of the Student

Note: Student will be charged Rs. 500/- for issue of Degree Certificate
For office use
Request received on

_______________________________________

Details of Payment

_______________________________________

Degree Certificate Issued on

_______________________________________

Authorised Signatory

_______________________________________

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