N.T.R.UNIVERSITY OF HEALTH SCIENCES, ANDHRA PRADESH, VIJAYAWADA-520008 APPLICATION FOR ISSUE OF PROVISIONAL CERTIFIATE (This is the prescribed Application Form for obtaining PROVISIONAL DEGREE CERTIFICATE to be filled up and to be submitted to this University through the Principal of the concerned college, by all those candidates who have passed their PG Degree / PG Diploma / Super Specialty Degree Examination only). 1) Full Name of the Candidate : ________________________________________________________________________________ 2) Surname of the Candidate : ________________________________________________________________________________ 3) Name of Father / Mother of the Candidate: ________________________________________________________________________________ 4) a) Provisional Certificate applied for :______________________________________________ b) Month and Year of Passing :______________________________________________ c) Registered No. / Hall Ticket No : _____________________________________________ d) College where studied and Passed the Degree Course / Examination: __________________________________________________________________________ 5) Details of fee paid: a) Amount : Rs: _________________ b) DD / Pay Order / NTR UHS Challan No: _________ Dated: _________ c) Name of the Bank : ________________ d) Place of the Bank : ________________________ 6) Full Postal Permanent / Temporary address (with PIN Code, Telephone No. Cell Phone No. ): ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ Station : ________________ Date : ________________ (Signature of the Applicant) (P.T.O.) -2- No format other than this shall be used. Please read the instructions / guidelines given in Page 2 before filling up. This application from may be down loaded by candidates through NTR UHS website No.http://203.199.178.93 FOR THE USE OF NTR UHS EXAMINATION WING ONLY TR Page No : PC No: Date of issue : Submitted: All the above details have been verified. DD / Pay Order has been sent to the Finance Wing. Hence, the Provisional Degree Certificate may be issued. Jr.Asst. Sr.Asst. Supdt. Asst. Registrar (Exams) Deputy Registrar(Exams) FOR THE USE OF PRINCIPAL'S OFFICE ONLY 1) Certified that the applicant, Dr. ____________________________________________ has completed the study period well before the exams were held / has completed the study period on ___________ by attending classes and wards even after the exams are over. 2) Certified that the applicant has no dues to the college. Hence, the Registrar, NTR University of Health Sciences is requested to issue the Provisional Degree Certificate as per the details furnished by the applicant from Serial No.1 to 6 of this application form. (Please delete the inappropriate wording in Certification 1 above) Station : ________________ Date : ________________ (Signature of the Principal with office seal) -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- INSTRUCTIONS & GUIDELINES TO THE APPLICANT 1) Use only Capital Letters. 2) All applications must be routed through the Principal of the College where the applicant has studied and passed the PG Degree / PG Diploma / Super Specialty Degree Examination. 3) Column No.1 & 2 of the application form : Full Name & Surname of the candidate: a) It should be written strictly as spelt in the UG Degree Certificate only. b) In case of those who want to obtain the PG Degree / PG Diploma / Super Specialty Degree Provisional Certificate as per the changed Name / changed Surname, the Full changed Name must be written as spelt in the AP Gazette / Proceedings of the NTR University of Health Sciences / Proceedings of the Director of Medical Education, Andhra Pradesh / Proceedings of the Director of Health, Andhra Pradesh OR any other Educational Authority. 4) Column No.3 of the application form : Name of the Father / Mother : It should be filled up only by those who are applying for issue of the Super Specialty Degree Provisional Certificate only. 5) Column No. 4 (a) of the application form: Permanent Degree Certificate applied for: Please specify whether applying for issue of MD / MS / MDS / MD (Ay) / MD (Homoeo) / M.Sc. (Applied Nutrition) / M.Sc. (Nursing) / DM / M.Ch. Degree Provisional Certificate. Also, please specify within brackets the concerned specialty of the Faculty, without fail. 6) Column No.5 of the application form: Details of fee: a) DD/ Pay Order for Rs.75/- is to be taken from any Nationalised Bank, payable at Vijayawada, in favour of THE REGISTRAR, NTR UNIVERSITY OF HEALTH SCIENCES, VIJAYAWADA. b) Blank Challan Form @ Rs.1/- is available at the NTR UHS Enquiry Counter which can be used for payment of above fee in the Syndicate Bank located in the NTRUHS Campus by those applicants who want to submit their applications at the NTR UHS Examination Wing Counter personally (But, even then, the application must be got routed through the Principal of the college as explained in Column No.2 above.) 7) Column No.6 of the application form: Full Address: This is required by NTRUHS to get certain doubts etc. if any, cleared from the applicant before or after issuing the Provisional Degree Certificate. ENCLOSURES: The following documents are to be enclosed to the application form securely tagged, in the order specified. 1) Copy of the Hall Ticket of the PG Degree / PG Diploma / Super Specialty Degree Examination. 2) Attested copy of UG Permanent Degree Certificate. 3) Attested copy of PG Permanent Degree Certificate (in case of those who are applying for Super Specialty Provisional Degree Certificate only in addition to Sl.No.2) 4) Self addressed Envelope with postal stamps worth of Rs.5/- for sending Provisional Certificate by ordinary post, Rs.27/- by Registered Post, Rs.30/- by Speed Post, whichever mode is desired. 5) If self addressed envelope with postal stamps is not enclosed, the Provisional Certificate will be dispatched by ordinary post by this University's Outward Dispatch Section. Note: (1) If the Candidate is in need of the Provisional Certificate urgently, he / she may visit the University in person to submit this application by 12.00 PM and to receive the Provisional Certificate personally by 4.00 PM on the same day. No double payment is necessary. (But, even then, this application must be got routed through the Principal of the college as explained column No.2 above.) (2) Without the copy of the Hall Ticket, Provisional Certificate cannot be issued personally. (photograph on the Hall Ticket will help to recognize the actual candidate) (3) Provisional Certificate cannot be handed over to others but will be sent to the applicant by post. ----- ------
