H.T.

No: COLLEGE
CODE

APPLICATION FOR PROVISIONAL CERTIFICATE

KUKATPALLY, HYDERABAD-500 072, A.P.

NAME OF THE CANDIDATE

*(IN BLOCK LETTERS AS PER S.S.C.)

FATHER’S NAME
(IN BLOCK LETTERS)

GENDER (Male/Female)

Degree / Diploma
COURSE AND BRANCH
Branch

MONTH & YEAR OF PASSING EXAM

(To be filled by the candidates, who completed the
Course)

PERMANENT ADDRESS

Pin code

FEE PARTICULARS: (Rs.200/-)

Bank: ______________________ D.D.No. ____________________ Date: ______________

NOTE:
1. Demand Draft for Rs. 200/- should be drawn in favour of the REGISTRAR,
J.N.T. UNIVERSITY, HYDERABAD. Payable at Hyderabad.
2. Xerox Copy of SSC Certificate should be enclosed. *

Date: SIGNATURE OF THE CANDIDATE

---------------------------------------------------------------------------------------------
For College Office Use Only
Certificate of Identification
I certify that Mr. / Mrs. / Miss.__________________________________________________
S/o / D/o of ________________________________________________is a Bonafied Student
of (College Name): __________________________________________________________
College Code: __________ during ___________ to _________ with H.T.No._____________

Date: Signature of the Principal

With Office Seal