XXII CONVOCATION of

BIRLA INSTITUTE OF TECHNOLOGY,

MESRA, RANCHI
(JUNE 2012)
Application for Attending Convocation
or Obtaining Degree in Absentia*
(Important: Pleasestrikeoffwhicheverisnotapplicable)
To
TheRegistrar,
BirlaInstituteofTechnology
Mesra,Ranchi835215

Date:.././2012[dd/mm]
Sir,
IamtostatethatIhavecompletedtheCourseofStudiesprescribedundertheRegulationsandhave
passedtherequisiteExaminationfortheAwardofDegreeintheXXIIConvocationtobeheldon03rd
June2012.
Mycompleteparticularsareasgivenhereunder:

Name(inEnglish,incapitals):

(inHindi):
InstituteRollNo....PlaceofStudy:MesraCampus/Extn.Cntr.(Place).
CompleteMailingAddress:|.
..
City/TownDist.&StatePINCode.
PhoneNo.(withSTDCode)/MobileNo.|...Email:
Examination Passed (Tickwhicheverisapplicable):Ph.D./M.E./M.Tech./M.Pharm./MBA/
MCA/M.Sc/B.E./B.Tech./B.Pharm./B.Arch./BHMCT/BBA/BCA/B.Sc.Degree
Month&YearofCompletion:.....(seeProvisionalCertificate)
Branch/FieldofSpecialization:....
Declaration:IwanttoreceivetheDegreeinPerson/inAbsentia[TicktheappropriateBox].

SignatureoftheCandidate:..

ThisApplicationshouldbesubmittedalongwiththefollowing:
Photocopy/scannedcopyoftheprovisionalcertificate
[You may communicate and send your application by email to : convocation2012@bitmesra.ac.in
Degree certificates of candidates who apply for receiving certificates IN ABSENTIA will be sent by
Registered/SpeedPosttotheaddressesintheirapplicationform].
NB:FilledinformswithnecessaryenclosuresshouldreachtheRegistrarby28thMay2012.
es8thMarch