DOWNLOADED FORM
Photostat copy of A.U. Registration Certificate and Marksheet of examination concerned (duly attested as in Rule overleaf) are to be enclosed.
ASSAM UNIVERSITY : SILCHAR
APPLICATION FOR OBTAINING DUPLICATE CERTIFICATE
(See overleaf for Rules)

1. Name in full (in Block letters) _______________________________________________________
2. A.U. Registration No. with year _________________________________of ___________________
3. Father’s/Husband’s Name in full ________________________________________________________________
4. Full Postal Address for Communication ________________________________________________________________
5. Details of Exam Passed for which duplicate certificate is applied for __________________________________________________
Examination Passed
Name of Board / University
Year of Passing
Examination Roll No.
Division / Class / Pass
Name of College / Dept.
6. Reasons for applying for Duplicate Certificate: _______________________________________________________
7. Fees paid:-
Amount in Rs.
Payment receipt No. & Date
Bank Draft No. & Date
Application No.
Date of Receipt
Dealing Asstt.
DECLARATION BY THE APPLICANT
I declare that the above particulars are true to the best of my knowledge and belief. If any statement is found to be incorrect, I understand that my application is liable to be rejected. I submit herewith the Police Report, Paper cutting and the Affidavit as required under rules.
Date : ………………….. Full Signature of the applicant
RECOMMENDATION OF THE HEAD OF THE INSTITUTION
This is to certify that Shri/Smt. ___________________________________________ Regn. No. ________________ of ___________ of A.U. a student of ___________________________ College / Deptt. passed the _________________ Examination of ________________ under Examination Roll________________ No. _______________ of Assam University and was placed in _________________ Class / Division / Pass. He may be allowed to obtain a Duplicate Certificate from the University as prayed for.
Memo No. ______________ Signature of the Principal/ Head PG Deptt.
Date ___________________ Name in full (in Block Letters)_______________________________
OFFICE NOTES & ORDERS
(1) Police Report, (2) Court Affidavit,
(3) Paper cutting & (4) Fees received. Records verified and found correct / incorrect.
Documents verified. Duplicate Certificate may be/ may not be prepared
Dealing Asstt.
Section Officer
Assistant Registrar (E)
Deputy Registrar (E)
RULES FOR OBTAINING DUPLICATE CERTIFICATE
1. Issue of Duplicate Certificate may be considered if the Original Certificate is lost by theft, burning or otherwise destroyed. In that case, this prescribed application completed in every respect should be accompanied by –
(A) AN AFFIDAVIT sworn before an Executive Magistrate/Judicial Magistrate (Class-I) by the applicant himself. The deponent must state in the affidavit (1) the name of the Certificate/Diploma (2) Roll No. (3) Year of passing (4) the College/department from where he/she passed the examination (5) the date & place of loss and (6) the circumstances under which the Certificate was lost or damaged.
(B) FIR (copy of the information lodged with the Police) OR a certified extract from the Police Diary containing the entry of the information lodged, with the seal of the Police Officer and the Police Station. In the Police Report also (1) the name of the Certificate (2) Roll No. (3) Year of passing (4) the College/department from where he/she passed the examination must be mentioned. Police Report should contain the G.D.E. No. & Date (of the Police Station).
(C) Copy of paper cutting containing advertisement regarding loss/ theft of certificate.
2. Duplicate Certificate may also be issued, when original certificate is defaced or mutilated or partially burnt /damaged and if the Certificate is surrendered to this office, giving convincing grounds, along with the application and necessary fees.
3. This application form duly filled in and countersigned, should be submitted to this office together with the prescribed fees and necessary documents mentioned in Rules 1(A) , (B) & (C) OR in 2 above. Besides this, the applicant shall be required to enclose with the application (1) duly attested Photostat copy of the A.U. Registration Certificate and (2) the duly attested Photostat copy of the Marksheet of the concerned Examination and (3) copies of paper cutting regarding loss/ theft etc.
4. All prescribed fees (as under) should be sent by Crossed Bank Draft in the name of Assam University payable at the State Bank of India, Dorgakona Branch OR deposited at the A.U. Cash Counter. The duplicate copy of the receipt to be enclosed with the application. The fee structures are under: -
Name of Examinations
Amount of fees
Master Degree
100.00
P.G. Diploma
100.00
Bachelor’s Degree
100.00
5. Generally the Certificate issued will be handed over to the applicant when his/her specimen signature will be attested in the form given below.
Specimen Signatures of the applicant to be attested by the Head of the Institution/Dean of the School of Assam University (as the case may be)
Specimen Signatures
1.________________________
2.________________________
3.________________________
Signature attested
Principal/Head of the
Institution/Head of the Department
with official Seal Allowed
C.O.E./Deputy Registrar (E)
2012-06-07