VEER MADHO SINGH BHANDARI UTTARAKHAND TECHNICAL

UNIVERSITY, DEHRADUN
(Formerly Uttarakhand Technical University, Established by Act No. 415 of 2005 by
Uttarakhand State Govt.)

APPLICATION FORM FOR ORIGINAL DEGREE/DUPLICATE DEGREE

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

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……………………………………………. . (Signature of candidate)

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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. (ORIGINAL DEGREE fee Rs 300/- (Three Hundred))
4. (Duplicate Degree fee Rs 400/-(Four Hundred)