APPLICATION FOR THE ISSUE OF A DUPLICATE PASS CERTIFICATE CONDUCTED BY THE STATE BOARD OF TECHNICAL EDUCATION AND TRAINING ANDHRA PRADESH : : HYDERABAD 1. Name of the Applicatn (in block : letters) 2. Address of the Applicant : 3. Father's Name : 4. Commercial Institute through which the applicant appeared for Examination 5. Serial Number and a Register Number of the Certificate issued tohim. 6. Number of times the appliacant appeared for the Certificate Examination with month and year of the examination and the Registered number assigned to each appearence. 7. Detailed circumstances under which the application for the issue of Duplicate certificate is made. 8. Whether the affidavit made on stamped paper for Rs.10/- regarding loss of the original certificate beyond recovery from the Magistrate is attached. 9. Whether the D.D. for Rs. of any Scheduled Bank in the state in favour of secreatary, State Board of Technical education and training, AP.,Hyderabad towards fee for issue of duplicate certificate is enclosed. NOTE: NAME OF THE BANK WITH D.D.NO.& DATE TO BE MENTIONED. 10. Whether the certificate has at any time been suspended OR Cancelled. 11. Whether any complaint was given to the police about the loss of Certificate, if so enclose copy of complaint along with the Police Enquiry Report. 12. Whether the copy of Marks list is enclosed. Contd....2 //2// D E C L A R A T I O N I solemnly declare that the particulars furnished above are true to the best of my knowledge and belief. DATED: SIGNATURE OF THE APPLICANT Note: The furnishing of In-Accurate or false particulars will details besides with holding of the Duplicates certifi cates such Disciplinary action as may be called for or deemed fit by the Secretary State Board of Technical Education and Training , A.P., Hyderabad. IDENTIFICATION CERTIFICATE OF THE PRINCIPAL I certify that the above particulars furnished by the candidate have been varified and found correct with the reference to the records of the institute and the applicant SRI/KUM.................................................... ..........................................................(Name to be given) is the same person to whom the Original Certificate was issued and the issue of the Duplicate to the candidates is recommended. STATION: SIGNATURE OF THE PRINCIPAL DATE: (WITH SEAL) D E C L A R A T I O N I do hereby that my Original Pass Certificate bearing Sl.No.........................................................with Regd.No.......................................................of the ....................................................State Board of Technical Education and Training, Andhra Pradesh, Hyderabad. is neither suspended not cancelled by the competent authority. DATED: SIGNATURE OF THE CANDIDATE Note: The following certificate s hould be send along with the applicant without fail. (1) Bank demand draft for Rs. 300/- infavour of the Secretary State Board of Technical Education and Training, A.P.. Hyderabad. (2) An affidavit on stamped paper worth of Rs. 10/- duly Signed by Ist class Magistrate. (3) A Declaration by the candidate that the Original Certificate was not suspended or cancelled, by the competent Authority. (4) An Identification cerficate from the concerned Principal of the Institute to the effect that the candidate same person to whom the original certificate was issued. (5) Police Enquiry certificate. (6) Pass port size Photos with Signature. Photo without Photo with Attestaion Attestation by any Gazetted Officer. C E R T I F I C A T E (Issued by the Gazetted Officer) This is to certify that Sri / Kum._______________________________________________________ S/o, D/o____________________________________________R/O_____________________________ has appeared for________________________________________Examination from _________________ centre and passed withregistered number_________________________________________________. The photo attested by me is of _______________________________________________________________ Dated: SIGNATURE C E R T I F I C A T E (Issued by the Institute Principal) This is to certify that Sri/Kum________________________________________________________ S/o, D/o_________________________________R/o,________________________________________ appeared for___________________________________________________Examination held in ___________ _____________from______________________________________Centre and passed the Examination with Registered number_________________.The photo attested by gazetted officer is of Sri/kum.__________ :__________________________________only. Dated: SIGNATURE *NM* A F F I D A V I T I.............................................................................................................................................................. Son of / Daughter of.......................................................................................................................................... Age..............................................Ocupation.........Resident of........................................................................... on solemnly oath and affirmation declare as under 1. That I have appeared for......................................................................................Examination held in the month of ..............................................19 with Regd.No............................. through.......... .......................................................................................................Institute/Polytechnic. 2. That the Original Certificate/Diploma issued to me by the state Board of Technical Education and Training has been lost by me while................................................................................................... details............................................................................................................................................. and inspite of my best effort, 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 indeed of duplicate copy of the said certificate/Diploma for which purpose, I am hereby making this declaration as required by the secretary state Board of Technical Education and Training, Andhra Pradesh, Hyderabad. Date: SIGNATURE OF DEPONENT (COURT SEAL) SWORN BEFORE ME. DATE: FIRST CLASS MAGISTRATE:
