UTTARAKHAND TECHNICAL UNIVERSITY, DEHRADUN

Post Office, Chandanwadi, Prem Nagar,Sudhowala, Dehradun

APPLICATION FORM FOR PROVISIONAL CERTIFICATE

To,
The Controller of Examination,
Uttarakhand Technical University, Dehradun

Sir,
I request you to kindly issue me the provisional degree certificate. The all
particulars of the examination passed me are given below.
1.Name in full English block letters …………………………………………………………………..
(As written in Examination form)
Name in Hindi ………………………………………………………………………………………
2. Father’s Name ……………………………………………………………………………………….
3.Mother’s Name……………………………………………………………………………………….
4.Roll No………………………………………………………………………………………………..
5.University Enrollment No…………………………………………………………………………….
6.Name of Institution…………………………………………………………………………………...
7.Name of Examination Passed………………………………………………………………………...
(Photocopy of marksheet must be enclosed with the application in support)
8. Year in which passed………………………………………………………………………………….
9. Division obtained……………………………………………………………………………………..

Address: - Yours faithfully

……………………………………………..
……………………………………………. . (Signature of candidate)
………………………………………………
Note:
1. The candidate should fill up this form correctly and legible in his/her own handwriting.
2. Provisional certificate will be issued only in case when final degree certificate is not ready.
3. (Provisional certificate fee Rs 100/- (Hundred))