Appendix ‘A’

SYMBIOSIS INTERNATIONAL UNIVERSITY

(Established under section 3 of the UGC act 1956 vide Notification No.F.9-12/2001-U.3 of the Government of India)
Accredited by NAAC with ‘A’ Grade
Gram - Lavale, Tal - Mulshi, Dist - Pune Pin Code – 411 042
Web Site: www.siu.edu.in, Email Address: coe@siu.edu.in, Phone: 39116223/24/25 Fax: 39116206

Application for VII Convocation

NOTE: This application is to be submitted to the Director of the respective institute.

(PLEASE READ IMPORTANT INSTRUCTIONS BEFORE FILLING THIS FORM)

To,

The Registrar,
Symbiosis International University
Lavale, Pune – 411 042

Sir,

Reference is made to Notification No. SIU/28/309 dated 12th Oct 2010 regarding Convocation 2010.
My details for Convocation are as under:
_______________________________________________________________________________________

A] PERSONAL DETAILS

1. Applicant’s Full Name in English (as it appeared in the grade sheet / statement of marks)

_______________________________________________________________________________________

2. Address for Correspondence / dispatch of degree / diploma certificate (In CAPITAL letters) :
House No. ____________________ Street ____________________________________________________
Area ____________________________________________________City ___________________________
Pin Code _________________________________State __________________________________________
Tel. No. (R) _________________________________Mobile _____________________________________
Email ID _______________________________________________________________________________

B] ACADEMIC AND OTHER DETAILS

3. Name of the Institute: _____________________________________________________________________
4. Name of the Programme : _________________________________________________________________
5. Month & Year of Examination: ____________________________________________________________
6. Permanent Registration No. (PRN): _________________________________________________________
7. Convocation Status
In Absentia - In Person -

I have carefully read & noted the instructions to the candidates before filling in this form. I declare that the
information given above is true and correct to the best of my knowledge and belief. I undertake that I shall be
responsible for any omission/errors and wrong/incomplete entries made by me in this form.

Yours sincerely

Signature: __________________ Date: ______________________.

 INSTRUCTIONS TO CANDIDATE

1. Incomplete forms or those without accompanying Xerox copy of Consolidated Statement of Marks will
be rejected and no correspondence in this behalf will be entertained.

2. Complaints regarding non-receipt of degree, issue or receipt of wrong degree (viz. name, college,
institute, class, subject, year of passing etc.) will be entertained within a period of one month only from
the date of receipt of convocation application.

3. Degrees not collected on the day of convocation will be sent by speed post after Convocation.

4. Applications for corrections of errors in the degree certificate will be entertained only within six months
from the date of convocation.

5. Last date for forwarding application form to the respective institutes is 15/11/2010.

6. Candidates pertaining to convocation 2004, 2005, 2006, 2007, 2008 & 2009 may also apply in another
form put up in the website.

…………………………………………………………………………………………………………………

For office use only: (Forwarded to the University)

Name of the Institute:

Remark if any:

Signature of the Director:

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