MANIPUR UNIVERSITY
CANCHIPUR, IMPHAL
APPLICATION FORM DUPLICATE MARK SHEET
1. Name of the candidate in full :
(in Block letters)
2. M.U. Registration No. . . . . . . . . . . of 19 . . . . . . . . . . College: . . . . . . . . . . . .
3. Father’s name :
4. Home address :
P.S. . .. . . . . . . . . . . . . . . P.O. . . . . . . . . . . . . . . . . District . . . . . . . . . . . . . .
5. Name of exam. passed/failed :
(Mention subject for TDC-III Year/M.A./M.Com./M.Sc).
Roll No. . . . . . . . . . . . . . Year . . . . . . . . . . . . . . . . Held in . . . . . . . . . . . . . .
6. Name of the college : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7. Specimen signature of the applicant (with address) or person authorized to collect the mark sheet.
Specimen signature and address in FULL.
(i) . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(ii) . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
The above particulars are true to the best of my knowledge and belief.
Date: . . . . . . . . . . . Signature of the applicant.
This is to certify that . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . a student of this college/department passed the . . . . . . . . . . . . . . . . . . . . . . . . . . Examination, 19 . . . . . (held in 19 . . . . ) under Roll No. . . . . . . . . . . . .and was placed in . . . . . . (Class/Division).
He/She may be allowed to obtain duplicate mark sheet from the University.
Official Signature of Principal/HOD.
NOTE: Application should be accompanied by an Affidavit sworn before a First Class Magistrate by the applicant, a copy of insertion in the Newspaper for the damage or loss of the original mark sheet and a Police Report.
No action shall be taken unless the application is duly filled in and a sum of Rs. 100/- only is received by the Office.
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