Phone: +919893655655

NATIONAL INSTITUTE OF TECHNOLOGY RAIPUR Email: examcontroller@nitrr.ac.in

(An Institute of National Importance under Ministry of Education, Govt. of lndia) Website: www.nitrr.ac.in

G.E. Road, Raipur, C.G. - 492010, India

APPLICATION FORM TO RECEIVE DEGREE/MEDAL IN PERSON

1. Name in English :
(As per last qualifying Examination Certificate submitted to Institute)
2. Roll No._ Passout Batch (Year)
3. Programme : Ph.D./M.Tech/MCA/8.Tech/B.Arch, Department
4. Current Mailing Address:_

P.O. District: State

PinCode: Email-ld

Phone/Mobile No. :(1) (2)

List of Attachments- Self attested photo copies of following certificates/testimonials. (Please
tick mark against attached documents)

1. Copy of valid 'ldentity Card' (Aadhar Card/Pan Card/Voter ld Card/Driving License/

Other with No.
2. Online Recipt/Reference No. of Rs. 1500/- fee payment (if not paid):

Declaration by Applicant
I acknowledge that the information on this form is true and correct. The details on this form
have been completed by me and not by other person.

Date
Student Signature

Verification by Department
I hereby confirmed that I have
personally known the person named as applicant above and I confirm
that I have sighted original document(s) that verified the
applicant name and residential address.

Date:
Signature& Seal_
Head of Department
Received by me (Tick Mark)

Degree Medal &Merit Certificate Grade Card /

Marksheet Transfer Certificate

Signature of Recipient