MANIPUR UNIVERSITY

CANCHIPUR, IMPHAL- 795003

APPLICATION FORM FOR PROVISIONAL CERTIFICATE

1. Name of candidate (In Block Letter) :

2. M.U. Regd. No. :
3. Name of the Examination :
4. Year of Examination :
5. Examination Roll. No. :
6. PhD Sl. No. :
7. Class :
8. Division :
9. Subject :
10. Mark Sheet No. :
11. Name of College :
12. Regular/Suppl./Private :
13. Please write title of Thesis/Dissertation :
*In Block Letters (for PhD / M.Phill. only)
*Attested copy of the PhD / M.Phil. Award Result sheet
14. Home Address/Village/Town P.O. & P.S :

* MIGRATED STUDENT: Students should submit an attested copy of Migration Certificate.

No action will be taken in the absence of the following documents.
a) An attested copy (Xerox) of Marks Sheet of the said examination.
b) An attested copy (Xerox) of Admit card of the said examination.
c) An attested copy (Xerox) of Registration Card.
d) An attested copy (Xerox) of Certificate/Marks sheet of HSLC.
e) PhD certificate: 1) Original/Attested Photocopy declaration result sheet for the degree of PhD
2) Original Copy of Registration Certificate of the University.

Provisional certificate Fee: Rs.30/- PhD course work fee Rs.50/-

The above particulars are true to the best of my knowledge and belief.

Application Date : .............................

(dd/mm/yyyy)

Mobile No. : ............................. Signature of the Candidate

FOR OFFICIAL USE

Received the certificate along with relevant documents Certificate/Sl. No. :.....................

Name : ..............................................

Date : ..............................................

Signature Signature Signature

Scribe/Certificate Section Asst. Certificate Asst. Registrar/Dy. Registrar