8-9-10-14187Duplicate Proforma

8/22/2019 8-9-10-14187Duplicate Proforma

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APPLICATION FOR THE ISSUE OF DUPLICATE / TRIPLICATE PASS

CERTIFICATE & DUPLICATE / TRIPLICATE CONSOLIDATED MARKS OF DIPLOMA

EXAMINATIONS CONDUCTED BY THE STATE BOARD OF

TECHCHNICAL EDUCATION AND TRAINING

ANDHRA PRADESH, HYDERABAD.

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01. Name of the Applicant :

(IN BLOCK LETTERS)

02. Fathers Name :

03. Address of the Applicant :

04. Polytechnic through which the applicant appeared :

for the Examinations.

05. Registration No./PIN of last appearances course, :

month and year of Examination.

06. Which of the following Duplicate Certificates :

required.

i). Duplicate/Triplicate Certificate

ii). Duplicate/Triplicate Consolidated Marksiii). Duplicate/Triplicate Memo of Marks.

07. Reasons for which the application for the issue of :

Duplicate Certificate/Consolidated Marks.

08. Whether any complaint was given to the Police :about the loss of the Certificates/Consolidated Marks

and a certificate to that extent from the above

authorities? If so enclose the same.

09. Whether the affidavit made on a stamped paper :

worth Rs. 20/- regarding loss of the Original

Certificates/Consolidated Marks and signed by theFirst Class judicial Magistrate is attached.?

10. Whether the DD for Rs._________ for Duplicate :

Original Certificate / Rs._________ for Duplicate

Consolidated Marks obtained towards fee from any

Nationalised Bank for issue of Duplicate/Triplicate

Original Certificate/Duplicate/Triplicate Consolidated

Marks. Furnish Bank Name, Number and date.

11. Whether the Diploma Certificate/Consolidated Marks :

has at any time been suspended or enclosed.

12. Whether any Photo copies of the above is enclosed :

for ready reference.

P.T.O.


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DECLARATION

I solemnly declare that the particulars furnished above are true to the best of my knowledge and belief.

Date: _______________ SIGNATURE OF THE APPLICANT

Note:- Furnishing of inaccurate and false particulars will be viewed seriously besides withholding of the Duplicate

Diploma Certificate and disciplinary action as may be called for or deemed fit by the Secretary, State Board

of Technical Education and Training.

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IDENTIFICATION CERTIFICATE OF THE PRINCIPAL

I Certify that above particulars furnished by the candidate have been verified and found correct withreference to the records of the Institute / Polytechnic and the applicant Sri/Smt/Kum. _______________________

_______________________________________________________ (Name to be given) is the same person to

whom the Original Diploma Certificate was issued and that the issue of Duplicate to the candidate is recommended.

Station: SIGNATURE OF THE PRINCIPAL

Dated: WITH SEAL

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DECLARATION

I do hereby declare that my Original Pass Certificate / Consolidated Marks Diploma bearing Sl.No.

________________________________with Regd.No./PIN_____________________________________ of

_________________________________ issued by the State Board of Technical Education and Training,Andhra Pradesh, Hyderabad is neither suspended nor cancelled by the competent authority.

Date: ____________. SIGNATURE OF THE CANDIDATE

Note:- The following Certificates should be sent alongwith the application without fail.

1. Bank Draft for Rs.2000/- for Duplicate Diploma Certificate & forRs.2300/- for Triplicate DiplomaCertificate. Bank Draft forRs.1000/- for Duplicate Consolidated Marks & forRs.1500/- for TriplicateConsolidated Marks for earlier schemes (i.e., Prior to 2000 Admissions).

2. Bank Draft for Rs.1500/- for Duplicate Diploma Certificate and forRs.1800/- for Triplicate DiplomaCertificate forC-00 & C-05 Schemes only.

3. An Affidavit in the prescribed proforma (copy enclosed) on stamped paper worth forRs. 20/- Certified byFirst Class Judicial Magistrate with the seal of the court concerned .

4. A declaration by the candidate that the Original Certificate/Consolidated Marks was not suspended orcancelled by the competent authority.

5. An Identification certificate from the concerned Principal of the Institute/Polytechnic to the effect that the

candidate is the same person to whom the Original Diploma Certificate was issued.

6. Police enquiry certificate in Original.

7. Photo copies of the Certificates if available.

8. Demand Draft should be drawn in favour of the Secretary, SBTET.. A.P., Hyderabad.

The application along with necessary enclosures should be forwarded to the Secretary, SBTET through the

Principal of the concerned Polytechnic.

Note:- 1) No documents are required for issue of Duplicate/Triplicate Memo of marks. Fee (Rs.500/-foreach

memo of marks) & Month/Year of passing the exam shall be clearly mentioned.


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A F F I D A V I T

I _______________________________________________________________________________

Son/Daughter of ________________________________________________________________________

Age ___________________ Occupation____________________________________________ resident of

________________________________________________________________________on solemnly oath

and affirmation do are as under.

1. That I have appeared for ____________________________________________________________

_____________ Examination held in the month of _____________________________________________

with Regd. No./PIN_____________________________________________________ through Polytechnic,

_____________________________________________________________________________________.

2. That the Original Diploma Certificate/PCCM issued to me by the State Board of

Technical Education and Training has been lost by me while _____________________________________

______________________________________________________________________________________

_________________________________ ( details ) ___________________________________________

______________________________________________________________________________________

_______________________ and in spite of my by best efforts I am unable to trace it and it is lost beyond

recovery. In case it is traced in future I shall submit it to the State Board of Technical Education and

Training, Andhra Pradesh, Hyderabad for cancellation.

3. That I am in need of Duplicate copy of the said certificate for which purpose, I am hereby making

this declaration as required by the Secretary, State Board of Technical Education and Training.

SIGNATURE OF DEPONENT

SWORN BEFORE ME

Date:

( Court Seal )

FIRST CLASS JUDICIAL MAGISTRATE

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8-9-10-14187Duplicate Proforma