Proviosional Certificate From Form – Fill Out and Use This PDF

Sam Higginbottom Institute of Agriculture, Technology and Sciences
	(Formerly Allahabad Agricultural Institute)		SHIATS
	Deemed-to-be-University
		A University
	DIRECTORATE OF DISTANCE EDUCATION
				With
		GLOBAL REACH
APPLICATION FORM FOR THE ISSUE OF PROVISIONAL CERTIFICATE
	Read the Instructions carefully before filling the Form
Enrollment Number (As in the ID card)	DESC Code	Programme

–

Name of the Student as registered with the University at the time of admission

Complete Address (Do not repeat the name)

e-mail Address

STD Code

Phone/Cell

Pin code

Demand Draft No.

Date

Amount

Name of the Bank

d

d

m

m

y

y

y

y

Rs.

1

5

0

(The Demand Draft of Rs. 150/- (One Hundred Fifty only) in favour of DDE, AAI-DU, A/c payable at Allahabad)

Academic Details

Sl.

Programme & Semester/Year

Month & Year of passing

DESC Code

Total Marks obtained in the Semester/Year

1

2

3

4

5

6

7

8

Note : Attach self-attested copies of Mark-Sheets of all Semesters/Years.

Declaration

I hereby declare that all the information given by me in this form are true and correct to the best of my knowledge and belief. I have attached all required documents and demand draft with this form.

Date

Place

Signature of the Student

For Hony. Co-ordinator, DESC Use Only

DESC Code

Phone/Cell

e-mail Address

It is certified that all the informations mentioned by the student in this Form are correct as per the record.

Date

Place

Seal & Signature of the Coordinator

Important Instructions

1.Provisional Certificate Form is to be filled by the student in his/her own hand writing in English, using black ball point pen very carefully in Block Letters only.

2.The address of the students must be complete in all respect. It is compulsory to mention PIN Code, Telephone/Cell No. and e-mail address (if any).

3.The Form having overwriting, striking out or erasure of any kind is liable to be rejected.

4.The Provisional Certificate fees is to be paid by demand draft of Rs. 150/- (One hundred fifty only) in favour of DDE, AAI-DU, A/c payable at Allahabad.

6.The Coordinator DESC and Students are required to retain the Xerox of the filled Form and the Demand Draft for future reference. The complete Provisional Certificate Forms along with demand drafts are to be sent on the following address:

The Assistant Registrar

Directorate of Distance Education

Sam Higginbottom Institute of Agriculture, Technology & Sciences

Naini, Allahabad - 211 007

Ph. : 0532-2684317

STUDENT NOT TO WRITE BELOW THIS LINE (For Office use only)