Rs. 10/-Form No. 68 Sl. No. To The Secretary/Controller of Examinations, Board of Secondary Education, Manipur, Imphal, Through the Headmaster/Headmistress/Principal. ............................................................................................................. ............................................................................................................. Subject :-Application for issue of ................................................................................... Sir, I have the honour to request you kindly to issue me ..................................................................... My particulars are given below : 1. Name in full (in block letters) ...................................................................................................................... 2. Father's name (in block letters) .................................................................................................................. 3. Mother's name (in block letters) ................................................................................................................. 4. Name of Examination ......................................... Roll .................... Year .............. Division ..................... 5. School from which appeared in the above Examination ............................................................................ 6. Regular/Private/External/Compartmental/Supplementary ....................... Date of Birth ............................ 7. Home Address : .......................................... Address of Correspondence : ................................. Village/Town etc. ........................................ Village/Town etc. ................................................... P.O. ........................... P.S. ........................ P.O. ................................... P.S. ............................. Dist. ............................................................ Dist. ............................................................................. 8. Whether the said document is to be sent by post/to be delivered to authorised person/to be collected personally by the candidate ........................................................................................................................ 9. Purpose for which the document is necessary ........................................................................................... 10. What happened to the original document .................................................................................................. 11. Mode of payment i.e. Cash/I.P.O. (In case of I.P.O. Please state No. and date of I.P.O.) ........................ Yours faithfully, Date ............................ Signature of the Candidate Memo No. .................................. Date .................................... Forwarded and recommended for issue of the above document which may be delivered to the person whose specimen signature is attested below : 1. 2. 3. Signature of the Head of the Institution Attested with seal. P.T.O. -: ( 1 ) : FOR USE IN THE OFFICE Statement verified and found correct. Dealing Assistant Section Officer May/May not be issued. Secretary/Controller of Examinations Here please write Duplicate Mark Sheet, Duplicate Admission, Original Certificate, Duplicate Certificate, Triplicate Mark Sheet, Triplicate Certificate, Migration Certificate, Provisional Certificate. Rate of fees : H.S.L.C. Examination : Duplicate Mark Sheet .................................................................... Rs. 50.00 Duplicate Admission Card .................................................................. Rs. 50.00 Duplicate Certificate ......................................................................... Rs. 100.00 Triplicate Certificate ......................................................................... Rs. 200.00 Triplicate Mark Sheet ....................................................................... Rs. 100.00 ...............2004 onwards .................................................................... Rs. 150.00 H.S.S.L.C. Examination : Duplicate Mark Sheet ....................................................................... Rs. 60.00 Triplicate Mark Sheet ...................................................................... Rs. 100.00 Duplicate Admission Card .................................................................. Rs. 50.00 Duplicate Certificate .......................................................................... Rs. 100.00 Triplicate Certificate ......................................................................... Rs. 200.00 Other Fees : Provisional Certificate, Mark Sheet 2004 onwards ............................ Rs. 150.00 Replacement of Certificate and Mark Sheet ................................... Rs. 50.00 Pre-issue of Certificate ..................................................................... Rs. 50.00 Migration Certificate .......................................................................... Rs. 100.00 Rank Certificate ................................................................................ Rs. 50.00 In case of regular candidates, the application must come through the Head of the Institution from which the candidate appeared at the Examination. In case of private candidates the application should come through the Head of the School form which the candidate appeared at the Examination. Please Note :- The application must accompany the followings: 1. An affidavit sworn before a 1st Class Magistrate by the father/guardian of the candidate if he/she is not a minor (for both duplicate/triplicate certificate only) 2. Police Report with the case diary number (for duplicate/triplicate certificate only) 3. A copy of the insertion in the News Paper for the loss/damage of the certificate. 4. For issue of duplicate mark sheets within three months from the issue of the original one, the application must accompany the documents stated in (1) and (3). In the event of partial damage of the certificate/mark sheet, enclose the remaining portion. -: ( 2 ) :
