MANIPUR UNIVERSITY
CANCHIPUR, IMPHAL
FORM NO.
APPLICATION FOR PROVISIONAL CERTIFICATE

1 Name of candidate in full :
(in Block letters)
2. M.U. Regd. No. :
3. Name of examination & Year :
Sc./Arts/Com./Diploma.
4. Examination Roll No. :
Class/Division/Subject.
5. Mark sheet No. :
6. Name of college :
7. Regular/Suppl./Private :
8. Please write the title of :
Thesis/Dissertation in block Letters (for Ph.D./M.Phil only). Attested copy of Award of the Ph.D./M.Phil. result sheet.
9. Home address/Vill./Town. : . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . ..
P.O. . . . . . . . . . . . . . .. … .. . : P.S. . . . . . . . . . . . . . . . . . . . . . .. . . . .. . . . .
10. MIGRATED STUDENT
Student should submit an attested copy of Migration certificate.
11. No action will be taken in the absence of the following documents :
(i) Original mark sheet of the examination.
(ii) Original Admit Card of the examination.
(iii) Original Registration Card.
(iv) Attested Xerox copy of certificate/mark sheet of HLSC.
12. Provisional Certificate Fee : Rs. 30/-
13. The above particulars are true to the best of my knowledge and belief.
Signature of the candidate
FOR OFFICIAL USE
Certificate/Sl.No. __________
Received the certificate along with relevant documents.
Name :
Date :
Signature of the Scribe. Signature of the Assistant Signature of the
Certificate Section. Certificate Section. Registrar/Dy. Regi.