C:\Users\ashish\Desktop\NO DUES FORM-12.

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UNIVERSITY INSTITUTE OF TECHNOLOGY
RAJIV GANDHI PROUDYOGIKI VISWAVIDYALAYA
Airpot By-Pass Road, Gandhi Nagar, Bhopal-462036. Tel-91-755-2678815, 12

To,
The Director Date : / /
UIT-RGPV, Bhopal
Sub. : Submission of No Dues Certificate.
Respected Sir / Madam,
It is to inform that I am leaving this institution on completion of Course / Transfer to other
institution / ..
I may kindly be issued following Certificate / Marksheets.
1- .... 3- ....
2- .... 4- ....
Yours faithfully
Sig.
Name .... S / D / W / of .
CDate : / /
ertificate For Students







S.N. Name of Department Dues
Concern
Asst.
sig. & date
Signature of
Concerned
Head
Remarks

1
CENTRAL LIBRARY Yes / No


2
Sports Officer Yes / No


3
SC / ST Section/Stationary Yes / No


4
HOSTEL WARDEN / CLERK Yes / No


5
UIT AA Yes / No


6
FEE CLERK Yes / No


7
HOD of Concerned Study Deptt. Yes / No


Enclosed : Student Identity Card.


Received all Certificates

Director
.. UIT-RGPV, Bhopal
Receiver Sig. & Date
No Dues Certificate for Student
Student Name _______________________________________Enrollment No._________________
Department __________Date of Admission in this institute in I yr / II yr______Passout yr. ________
Semester studied _______________ to _________________
Course : B.E. / MCA / M.Sc. / M.E. / M. Tech. Branch_____________Mob. No.________________
Category : Mark

GEN OBC SC ST