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

_______________________________________