BOARD OF SECONDARY EDUCATION, ORISSA, CUTTACK Visit us at: www bseorissa.in os ae a DPC Issued Vide re ee 0 Book $1. No. On ioael Dated Signature of D.AJS.O./A.S. FORM OF APPLICATION FOR DUPLICATE CERTIFICATE (APPLICATION INCOMPLETE/INCORRECT INANY RESPECT IS LIKELY TO. BE REJECTED) 1. FuName ofthe Candidate ncaa ta seni ota ora (Name and Complete Postal Address of the Applicant) No. me: . Ro : vist va, Pn 2.) Fathers Name cause nee oka fae eaten oof a ata (©) Roll No. {3 © Date of ith Roll No. and year of the Examination Passed : Name of the School from which appeared : Name of the Centre Dela Ciera ia eH application for 1s’2nd Duplicate Pass Certificate is made. ?. Whether an affidavit sworn before an Executive Magistrate regarding the loss, theft or damage of the ‘ Original Pass Ceticat beyond recoveryipatiaciod? Yesito 8 Whetherthefeeof’ 1.1000/— ‘ispaid? State the Te are Del Ala SBGI DIOR ND. ie pe 9. Fees for TATKALRs. 2000 /— «is paid by Cash. qo. nether apples forte itor 2ndDupcate Ceticate? * {'solemnly declare that the particulars fumished above are true. Date. egne Full Signature of the Applicant Full Signature of the Applicant must be attested by a Gazetted Officer with seal IFICATE FROM THE HEAD OF THI TTUTION Cerified that (I) SrVSmt. cc . son/daughter of Smt. (mother) Sri m ee (Father) passed the - Examination held in the month of ee 2Ol, with Roll No. His/Her date of birth as recorded in the Admission Register of the School is éannsnies HO/SME WAS PlACEM AM orem snes Division, (i) Thatthe above pantculars furnished by the candidate/Duplicate pass Certificate bearing SI. No. and the issue of the 1sv’2nd Duplicate is recommended. Full Signature of the Headmaster Headmistress with Seal & Address of the School At Memo No. ‘ ot Po. * One Passport size photograph duly Via attested by the Headma: eee Dist. ‘ Pin, Secretary for C.C, Candidates)to be attached for the A,HSC Exem.2011 & onwards.(2) NOTE: 1 10. 11 12. In case of theft / loss of the original Certificate the matter should be reported to the nearest Police Station. The endorsement as given in the application form be obtained. In case of loss of the Certiicate due to flood or fire a Certificate to the effect from.the concemed Tahasildar should be attached. Incase the Certificate is parily destroyed or defaced another certiticate willbe issued after due scru- tiny and on surrender of such certificate. Rate of fees forthe 1st duplicate certificate is Rs. 510/-\Rs.710/- Rate of fees for 2nd duplicate cert cate is Rs. 1010/\Rs. 1510/- which will be paid in shape of Bank Draft payable to the Secretary, B.SE., Orissa, Cuttack along with the application, A private candidate shall apply for the duplicate through the Head of the Institution who has attested his/her application for the examination. (Direct Private candidate of the Board : Passed under the old Regulation should apply through the Inspector of Schools of the concemed circle). An affidavit duly swom in the prescribed form before the Executive Magistrate should be attached ‘along with the Bank Draft made payable to the Secretary Board of Secondary Education Orissa, Orissa, Cuttack, ‘The duplicate Certificate in ell cases shall be sent to the concemed Head of the Institution only. ‘The duplicate Certificate may be made available for despatch to the School concemed after 120 clear working days (excepting Sundays and Holidays) from the date of receipt of the application with the prescribed fees complete in all respect, ‘The Board shall not however be responsible for delay in preparing duplicate certificate due to unavoid: able circumstances. Head of the institution who recommends for the duplicate certificate will mention i the candidate applies for the 1st or 2nd DUPLICATE CERTIFICATE. Signature of the applicant must be attested by a Gazetted Officer with seer. Xerox copy ofthe Original Pass Certificate (i any) Provisional Certificate cum-Memorandum of Marks be attached along with the application form. i AFFIDAVIT} VSHUSMt, roe i - Son/daughter of Smt. . (mother) Sr... sentintimnnrene (FANNER) AE =n... YEARS resident of ‘on solemn oath and affirmation ‘occupation ... State as under That Ihave passed the ...nnnnnin ssnnnnnnntnannsXaMination held in the month Of crnnnee 201 ne Beating ROM NO. ennnn through school ‘That the Original Pass Certificate which was issued to me by Board of Secondary Education, Orissa has been lost/stolen/damaged due to floodire (use the word which ever is required) and inspite of my best effort | am unable to trace it out and itis beyond recovery. In case itis traced out in future | shal submit it to the Board of Secondary Education, Orissa for cancellat That | am in need of duplicate copy of the said certificate tor which purpose | hereby make with the declaration as required by the Secretary, Board of Secondary Education, Orissa. That the facts stated in paragraphs 1 to 3.are true to the best of my knowledge and belie! Advocate By the Deponent I centfy the at Sr#Smt son/daughter of who is indented by Sri ‘ f Advocate .. has swom and signed this affidavit before me today the of ‘of (month) 201 Executive Magistrate Office Seal