FORM OF APPLICATION FOR "DUPLICATE CERTIFICATE" 1.(i) Name of applicant (in block letters) ; ______________________________ (ii) Man/Woman : ______________________________ 2. Father's Name : ______________________________ 3. Mother's Name : ______________________________ 4. Date of Birth : ______________________________ 5. Name of the Examination in respect Of which the duplicate certificate is Required : ______________________________ 6. Year of passing the Examination : ______________________________ 7. Roll No under which he/she passed/ Failed with name of Centre : ______________________________ 8. Name of Institution from where Passed/failed : ______________________________ 9.(i) Did you received the original Certificate from the department Through the Head of Institution or Direct. : ______________________________ (ii) Date of receipt of original certificate Approximate if exact not known : ______________________________ 10.(i) Reason for applying duplicate copy of Certificate : ______________________________ (ii) Approximate date when the certificate Was lost/damaged : ______________________________ 11. Present full address of the applicant For dispatch of certificate : ______________________________ 12. No. & date of receipt under which Rs.15/- was deposited. : ______________________________ 13. Name of the Institution in which Applicant is/was reading at present/ Past : ______________________________ Date: ......... (Signature of the applicant) It is certified that Sh/Smt. ______________________________ Son/Daughter of Sh.________________________ appeared in the class ___________________________ Examination in the year ___________________________ under Roll No. ____________ From _______________________ Chandigarh. Dated: .......... Signature of Head of the Institution with Seal AFFIDAVIT (SPECIMEN) (On Non-Judicial Stamp Paper of Rs.3/-) I, _____________________________________ Son/Daughter of _____________ resident of ______________________________________________ do hereby solemnly affirm and declare as under:- 1. That I (in case of Adult) my son/daughter (in case of minor) _________________ appeared in the Middle Standard/E.T.T./N.T.T/O.T.Examination in the year___________ from ____________________________________ Education Department from ________ ______________________________________ (School). 2. That my/his Roll No. was ________________ vide which I or he/she passed the Middle Standard/E.T.T./N.T.T/O.T.Examination. 3. That the certificate issued to me or him/her by the Education Department has been misplaced and the same is not traceable. 4. That I undertake to return the same, if found at any stage and I further undertake not to misuse the said certificate if found at any stage. 5. That this affidavit is being submitted to obtain a duplicate copy of certificate of Middle Standard/ E.T.T./N.T.T/O.T.Examination. Note: 1. Certificate issued in respect of the examination held by the department other than those issued by the erstwhile Education Department in respect of the examination held in or before the year 1966 will not be issued by the department. 2. This form of application should be filled in neatly accurately by the applicant after reading the note given below and submitted to the Registrar Examination. Education Department, Chandigarh Administration through the Head of the Institution concerned. 3. E.T.T/N.T.T./O.T. and Middle Standard Examination fee for issue of duplicate certificate is Rs.15/- 4. The application from should be accompanied with an affidavit on Non-Judicial stamp paper of Rs.3/- duly attested by the Magistrate 1st Class, Chandigarh. 5. No amount will be accepted either in postal order and Bank Draft etc. 6. The private candidates are asked to get the Forms attested from any Govt/Aided Institute or the Institution from where they submitted their initial forms at the time of appearing in the above examination.
