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Provisional and Duplicate Certificate Application

The document is an application form for a provisional pass certificate, consolidated mark card, or duplicate mark card from Manipal Academy of Higher Education. It requests the issue of one of these documents and provides details like the applicant's registration number, name, course information, and reason for request. For a duplicate mark card, an affidavit and police complaint copy must be enclosed if the original was lost or damaged. The format of the affidavit to be submitted is also provided, requiring the applicant to attest that the original certificate was lost despite searching, has not been misused, and a certified duplicate is now needed.

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Leno Benny
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239 views2 pages

Provisional and Duplicate Certificate Application

The document is an application form for a provisional pass certificate, consolidated mark card, or duplicate mark card from Manipal Academy of Higher Education. It requests the issue of one of these documents and provides details like the applicant's registration number, name, course information, and reason for request. For a duplicate mark card, an affidavit and police complaint copy must be enclosed if the original was lost or damaged. The format of the affidavit to be submitted is also provided, requiring the applicant to attest that the original certificate was lost despite searching, has not been misused, and a certified duplicate is now needed.

Uploaded by

Leno Benny
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

Application for issue of PROVISIONAL PASS CERTIFICATE /CONSOLIDATED MARK

CARD/DUPLICATE MARK CARD (fill the details which are applicable)

Reg. No.:
NAME
(in Capital letters)
Institution Name

Course name
Branch/ Month & Year
Specialization of passing
Tel/Mobile No.: e-Mail:

Request for the issue of


Month & Year of passing :
 PROVISIONAL PASS CERTIFICATE Internship Completion date:
(enclose copy of the certificate,
Applicable for MBBS, BDS & Allied Health Science courses)
Year/Sem.:

 CONSOLIDATED MARK CARD ____________ number of original mark cards enclosed.


( Enclose all original mark cards for issue of consolidated mark cards)

 _______ number of damaged original mark cards


 DUPLICATE MARK CARD Enclosed:
 Affidavit and FIR copy
Note: i. Enclose damaged/mutilated original mark card(s) for replacement with duplicate mark card(s).
ii. In case of misplace/loss of mark cards, enclose an affidavit (refer overleaf for format of the affidavit) and copy
of police complaint (FIR) for duplicate mark card.

Details of fees paid


DD/Challan/ Receipt No. and date Bank Name Amount (₹)

Place:

Date: Signature of the Candidate

For official Use


Verified and Recommended
 It is certified that the candidate has cleared all dues.

Verifier Name:
Signature: Signature & Stamp of the
Head of the Institution
STN019
FORMAT OF THE AFFIDAVIT (on ₹20/- Non-Judicial Stamp Paper)

Before the Registrar-Evaluation, Manipal Academy of Higher Education


(Deemed to be University) Manipal, Udupi District, Karnataka, India

…….…………...….……………………………………….(Name of the Student), ….………….….Deponent

AFFIDAVIT

I, …………………………….…………….….……. son/daughter of .……….…………………………….……...

aged………………residing at……….……………………………………….. solemnly affirm and state


as follows:

1. I say that I have misplaced the originals of the following certificates issued by the
Manipal Academy of Higher Education (Deemed to be University), Manipal

a) Registration Number b) Particulars of the Certificate Lost:

2. I say that in spite of diligent search I am unable to trace the originals of the
aforesaid certificates and hence they are taken as lost. If traced, I will produce
them before the Manipal Academy of Higher Education (Deemed to be University),
Manipal.
3. I say that I have not misused the same and I shall not misuse the same if
recovered.
4. I say that for the purpose of …………………………………………………………………. I need
the certified duplicates of the said certificates.
5. It is therefore necessary that on the strength of this affidavit certified duplicates
are issued to me by Manipal Academy of Higher Education (Deemed to be
University), Manipal at my cost.
6. All this is true.

DEPONENT

Solemnly affirmed and signed before me on this day of ………..………..…………………………….

…………….…………………………………………dt………………………………………………

NOTARY PUBLIC

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