केरऱ केन्द्रीय विश्िविद्याऱय

CENTRAL UNIVERSITY OF KERALA

APPLICATION FORM FOR PROVISIONAL DEGREE CERTIFICATE

( Please Fill up in Block Letters. All fields are compulsory, incomplete application will not be accepted)

1. Name of the Applicant ----------------------------------------------------------2.Reg.No--------------------

3. Father’s Name----------------------------------------------------------------------------------------------------

4 .Name of the Examination passed-----------------------------------------------------------------------------

5. Year and Month of Passing-------------------------------------------------------------------------------------

6. CGPA ------------------------------------------------------7. Class: ----------------------------------------------

8.Details of Additional Examination (if any)

Semester Month & Year of Passing Subjects appeared No of attempts

9. Fee of Rs. 220/- remitted vide cash receipt No.--------------------and Date----------------------------

or Demand Draft No----------------------of----------------------------Bank Dated -------------------------

10. Copy of No Dues certificate produced : Yes / No

11.Self attested copy of Previous Qualifying Degree /Examination attached: Yes / No
12.Details of Previous qualifying Degree/Examination:

Name of University/ Name of the Duration CGPA %ge Class Year of

Degree Board Institution last In Years of passing
studied marks

13.Recommentation of HoD with date & Sign:------------------------------------------------------------------

(P.T.O)
14. Address of the student:

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Mobile No: ……………………………………………………………… (Signature of the applicant with date)

PS :
1. For receiving the Certificate within India by registered post please enclose postage of Rs. 50/- & for receiving
the certificate abroad, Please contact Examination Branch Tel: 04672309466, 04672309467
2. Demand Draft should be drawn in favour of the Finance Officer, Central University of Kerala, payable at any
Public Sector Bank in Kasaragod or Periye
3. Please print this form on both sides of an A4 sheet.

FOR OFFICE USE ONLY

---------------------------------------------------passed the----------------------------------------------examination
held in -----------------------------------------20---- under Roll No.----------------------------- The application
is in order and the payment has been verified. The candidate may be issued with Provisional
Certificate.

Entered on Page----------------------- at Sr.No ------------------------ of the Provisional Certificate issue

Register.

DA Assistant SO / AR

Approved/ Not Approved

Date: Controller of Examinations