APPLICATION FOR THE ISSUE OF DUPLICATE S.S.L.C./H.S.M.P.S.L.C. 1. Name of the applicant (Block letters) 2. Address of the applicant (to be given clearly) 3. Father's Name 4. Date of Birth 5. School where the applicant last Studied 6. Serial number of the original S.S.L.C. 7. No. of times the applicant Appeared for the S.S.L.C. Public examinations with the Month and year of the examination And the Register Number assigned to each appearance. (Correct particulars should be given) 8. Detailed circumstance under Which the applicant for the Issue of duplicate S.S.L.C Is made 9. Whether certificate regarding The loss of the original S.S.L.C. beyone recovery from A Government Official not Lower than the deputy Tahsildar Or S.I. of Police is attached. 10. Whether the Challan for Rs.10/- or 15/- towards fees for obtaining a duplicate S.S.L.C. in enclosed (Name of the Government) Treasury and Number and date of the Challan to be mentioned. 11. Whether the S.S.L.C. has at Any time been suspended or Cancelled. 12. Whether the candidate his at any Time been debarred for appearing For the S.S.L.C. Public Examination Due to resporting to malpractice etc., If so definite particulars mey be Furnished. DECLARATION I solemnly declare that the particulars furnished are true to the best of my knowledge and belief. Signature of the Applicant. NOTE: The furnished of inaccurate of false particulars will anter of with holding of the duplicate certificate and in the case of false particulars such disciplinary action as may be called for or deemed fit by the Commissioner for Government Examinations. CERTIFICATE OF THE HEADMASTER I certify that the above particulars furnished by the candidate have been verified and found correct with reference to the records of the school and the applicant Sri (Name to the given) to the identical person to whose S.S.L.C. was originally issued is recommended. SIGNATURE OF THE HEADMASTER/ HEADMISTRESS AND WITH STAMP. Note: fee should be paid into a Government Treasury and under the Head of Account "0202 Education - 01 General Education Minor Head 102 sec. Education, Sub-Head (01) Examinations fee (02) other fee. The application and its necessary enclosures should be forwarded to this office through the Headmaster there he/she last studied and through District Educational Officer concerned. NECESSARY ENCLOSURES 1. Challan No.10/15 (in the case of HSMPSLC Certificate Rs.15/-) 2. Certificate regarding loss of the Original S.S.L.C (vide item No.9) 3. Extract of the First page of the S.S.L.C. (to be issued by the Headmaster concerned). 4. Declaration by the candidates separately (vide item No.11 and 12) 5. The application should invariably mention the roll No. years and centres at which he appeared for the Examinations. If, the Roll Nos. are not available at least year and centres should be furnished (vide item No.7) 6. The application with all its enclosures should be submitted to this office through the Headmaster/Headmistress of the school where he/she studied and the District Educational officer concerned.
