APPLICATION FOR THE ISSUE OF DUPLICATE / TRIPLICATE PASS CERTIFICATE & DUPLICATE / TRIPLICATE CONSOLIDATED MARKS OF DIPLOMA EXAMINATIONS

CONDUCTED BY THE STATE BOARD OF TECHCHNICAL EDUCATION AND TRAINING ANDHRA PRADESH, HYDERABAD. *********** 01. Name of the Applicant (IN BLOCK LETTERS) Fathers Name Address of the Applicant Polytechnic through which the applicant appeared for the Examinations. Registration No./PIN of last appearances course, month and year of Examination. Which of the following Duplicate Certificates required. i). Duplicate/Triplicate Certificate ii). Duplicate/Triplicate Consolidated Marks iii). Duplicate/Triplicate Memo of Marks. Reasons for which the application for the issue of Duplicate Certificate/Consolidated Marks. Whether any complaint was given to the Police about the loss of the Certificates/Consolidated Marks and a certificate to that extent from the above authorities? If so enclose the same. Whether the affidavit made on a stamped paper worth Rs. 20/- regarding loss of the Original Certificates/Consolidated Marks and signed by the First Class judicial Magistrate is attached.? Whether the DD for Rs._________ for Duplicate Original Certificate / Rs._________ for Duplicate Consolidated Marks obtained towards fee from any Nationalised Bank for issue of Duplicate/Triplicate Original Certificate/Duplicate/Triplicate Consolidated Marks. Furnish Bank Name, Number and date. Whether the Diploma Certificate/Consolidated Marks has at any time been suspended or enclosed. Whether any Photo copies of the above is enclosed for ready reference. :

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P.T.O.

DECLARATION
I solemnly declare that the particulars furnished above are true to the best of my knowledge and belief. Date: _______________ SIGNATURE OF THE APPLICANT

Note:- Furnishing of inaccurate and false particulars will be viewed seriously besides withholding of the Duplicate Diploma Certificate and disciplinary action as may be called for or deemed fit by the Secretary, State Board of Technical Education and Training. --------------------------------------------------------------------------------------------------------------------------------------------

IDENTIFICATION CERTIFICATE OF THE PRINCIPAL

I Certify that above particulars furnished by the candidate have been verified and found correct with reference to the records of the Institute / Polytechnic and the applicant Sri/Smt/Kum. _______________________ _______________________________________________________ (Name to be given) is the same person to whom the Original Diploma Certificate was issued and that the issue of Duplicate to the candidate is recommended.

Station: Dated:

SIGNATURE OF THE PRINCIPAL WITH SEAL

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DECLARATION
I do hereby declare that my Original Pass Certificate / Consolidated Marks Diploma bearing Sl.No. ________________________________with Regd.No./PIN_____________________________________ of _________________________________ issued by the State Board of Technical Education and Training, Andhra Pradesh, Hyderabad is neither suspended nor cancelled by the competent authority.

Date: ____________.

SIGNATURE OF THE CANDIDATE

Note:- The following Certificates should be sent alongwith the application without fail.
1. Bank Draft for Rs.2000/- for Duplicate Diploma Certificate & for Rs.2300/- for Triplicate Diploma Certificate. Bank Draft for Rs.1000/- for Duplicate Consolidated Marks & for Rs.1500/- for Triplicate Consolidated Marks for earlier schemes (i.e., Prior to 2000 Admissions). Bank Draft for Rs.1500/- for Duplicate Diploma Certificate and for Rs.1800/- for Triplicate Diploma Certificate for C-00 & C-05 Schemes only. An Affidavit in the prescribed proforma (copy enclosed) on stamped paper worth for Rs. 20/- Certified by First Class Judicial Magistrate with the seal of the court concerned . A declaration by the candidate that the Original Certificate/Consolidated Marks was not suspended or cancelled by the competent authority. An Identification certificate from the concerned Principal of the Institute/Polytechnic to the effect that the candidate is the same person to whom the Original Diploma Certificate was issued. Police enquiry certificate in Original. Photo copies of the Certificates if available. Demand Draft should be drawn in favour of the Secretary, SBTET.. A.P., Hyderabad.

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The application along with necessary enclosures should be forwarded to the Secretary, SBTET through the Principal of the concerned Polytechnic. Note:- 1) No documents are required for issue of Duplicate/Triplicate Memo of marks. Fee (Rs.500/-for each memo of marks) & Month/Year of passing the exam shall be clearly mentioned.

AFFIDAVIT I _______________________________________________________________________________ Son/Daughter of ________________________________________________________________________ Age ___________________ Occupation____________________________________________ resident of ________________________________________________________________________on solemnly oath and affirmation do are as under. 1. That I have appeared for ____________________________________________________________

_____________ Examination held in the month of _____________________________________________ with Regd. No./PIN_____________________________________________________ through Polytechnic, _____________________________________________________________________________________. 2. That the Original Diploma Certificate/PCCM issued to me by the State Board of

Technical Education and Training has been lost by me while _____________________________________ ______________________________________________________________________________________ _________________________________ ( details ) ___________________________________________ ______________________________________________________________________________________ _______________________ and in spite of my by best efforts I am unable to trace it and it is lost beyond recovery. In case it is traced in future I shall submit it to the State Board of Technical Education and Training, Andhra Pradesh, Hyderabad for cancellation. 3. That I am in need of Duplicate copy of the said certificate for which purpose, I am hereby making

this declaration as required by the Secretary, State Board of Technical Education and Training.

SIGNATURE OF DEPONENT

SWORN BEFORE ME Date: ( Court Seal ) FIRST CLASS JUDICIAL MAGISTRATE