Form No: PH19

INDIAN INSTITUTE OF TECHNOLOGY (INDIAN SCHOOL OF MINES) DHANBAD

OFFICE OF THE DEAN (ACADEMIC)

FORM FOR ISSUING COMPLIANCE OF UGC REGULATIONS CERTIFICATE / PH.D

COURSE WORK CERTIFICATE / PROVISIONAL PH.D CERTIFICATE
[Please send the duly filled-in form with enclosures to certificates@iitism.ac.in]

1. Name of Scholar
2. Admission No. Department
3. Branch (if any)
4. Email ID
5. Contact Number
6. Father’s / Guardian Name

Month & Year of Month & Year of Completion

7.
Admission at IIT (ISM) of Academic Program

Communication Address
8.
(with Pin Code)

9. Request for a particular certificate and the documents to be submitted:

Sl. Please
Certificate Document to be submitted
NO Tick
Scan Copy of Course Work Result Notification or
(i) Ph.D Course Work Certificate
Grade Sheets
(ii) Provisional Certificate
Scan Copy of ID / Final Result Notification
(iii) Compliance of UGC Regulations Certificate

Date:______________ Signature of the Student ________________________

FOR OFFICE USE ONLY

Verification:
The facts, as stated above are CORRECT/NOT CORRECT Date of Receipt of Application:
as per records available. _______________________________________
Remarks, if any:
________________________________________________ Issuing Date of Certificate:
_______________________________________
________________________________________________

Date:___________ Date:___________

Signature of Dealing Assistant AR (Academic – UG/PG)