OFFICEOFTHECONTROLLEROFEXAMINATIONS

ANNAUNIVERSITY,CHENNAI600025

APPLICATIONFORISSUEOFDUPLICATECERTIFICATE

Certificateforwhichappliedfor*

Degree/Branch

Collegethroughwhich
Studied/Studying

Detailsofpaymentmade

DemandDraftNo.
DDDate
:

Bank
:

AmountpaidRs.:

1.NameoftheStudent

2.RegistrationNumber

3.Sex

4.(a) IfapplyingforduplicateStatementofMarks/
GradeSheet,fillintheMonthandYearofExam
forwhichStatementofMarks/GradeSheetisrequired

(b) IfapplyingforduplicateDegreecertificate,fillthe
(i)MonthandYearinwhichqualifiedfortheDegree

(ii)DateofconvocationinwhichtheDegree
wasconferred

(c) IfapplyingforDuplicateProvisionalCertificate/
ConsolidatedStatementofMarks/Gradesfillinthe
Month&Yearoflastappearanceinwhich
qualifiedfortheDegree

5.Circumstancesunderwhichthecertificatewaslost

6. Whethertheprescribedaffidavithasbeenenclosed
withtheapplication

7. Addresstowhichthecertificateistobesent

Place:

Date:

SIGNATUREOFTHECANDIDATE
FOROFFICEUSEONLY

Certificateissuedon :

Preparedby

FolioNo.

Examinedby

DateonwhichtheD.D.was
senttoFinanceSection:

CONTROLLEROFEXAMINATIONS

*WriteasDegreeCertificate/StatementofMarks/GradeSheet
ProvisionalCertificate/ConsolidatedStatementofMarks/Grades.
(PleaseseeInstructions)

INSTRUCTIONS

1. Duplicatecertificatewillbeissuedonlywhenitislostordestroyedirrevocably.

2. Applicationshouldbemadeonlybythecandidateintheprescribedformatandshouldbe
sent to theControllerof Examinations directly. Application received on behalf of the
candidatewillnotbeaccepted.

3. Thefollowingdocumentsshouldbeenclosedalongwiththeapplication.

(a) an affidavit explaining the circumstances under which the original certificate was
lost.

TheaffidavitshouldbedulyexecutedintheprescribedformatbeforetheNotaryPublic/
PrincipaloftheCollegewherehe/shehadstudied.

(b) selfaddressedstampedenvelope(forRegisteredPost).
(c)photocopy of the Statement of Marks / Grade Sheet / Degree Certificate for which
duplicateisrequired(ifavailable).
(d) theDemandDraft.

Inadditiontotheabove,candidatesapplyingfortheDuplicateDegreeCertificate
shouldenclose:

(e) Non traceablecertificateobtainedfrom the Police Authority.

(f) The original Daily Newspaper(Registered)inwhich Notification was issued
forloss ofcertificate.

4. WhilepublishingsuchnotificationintheDailyNewspaper(Registered),thenameofthe
applicantwithinitial,RegistrationNo.,NameoftheUniversityinwhichcertificatewas
obtainedetc.tobeprovidedwithoutfail.

5. Application should be completed in every respect. Failure to furnish correct details

maycausedelayintheissueofthecertificate.

6. Thefeefortheissueofvariouscertificateisasfollows:

(a)StatementofMarks/GradeSheet

Rs.200/each

(b) ProvisionalCertificate

Rs.500/uptoConvocation.
NoProvisionalCertificatewillbeissued
aftertheConvocation.

(c)ConsolidatedStatementofMarks/Grades

Rs.500/

(d)DegreeCertificate

Rs.3000/

7. ThefeeshouldbepaidintheformofDemandDraftdrawninfavouroftheCONTROLLER
OFEXAMINATIONS,ANNAUNIVERSITY,CHENNAIpayablebranchatChennai.

8. Fee once paidwill notbe refunded or adjusted for anyother certificate under any
circumstances.

9. Duplicate Certificate is to be surrendered to the University immediately if the Original

Certificateisrecoveredlater.

AFFIDAVITTOBEFILEDFORISSUEOFDUPLICATECERTIFICATE

AffidavitofThiru/Selvi

1. I...Son/Daughterof

.aged.. Years,
anoldstudent/studentof.Degree of..
collegewithRegisternumberandresidingat.
....

doherebysolemnlyandsincerelystateasfollows.

2.My (i)*Statementofmarks/GradeSheetissuedrelatingtotheExaminationsheld during

(ii)*DegreecertificateissuedattheConvocationheldon
(iii) * Provisional Certificate / Consolidated Statement of Marks / Grades issued by the

AnnaUniversityhasirrevocablybeenlost/destroyed.

3.Ifilethisaffidavitforthepurposeofreceivingduplicatecertificate.

4.I will returnimmediatelythe duplicatecertificate(s)to the University once my original

certificate(s)is/arerecoveredlater.

5.The facts stated are true and correct to the best of my knowledge and if found false by the

University,IshallabidebythedecisionoftheUniversity.

Place :

Date :

SIGNATUREOFTHECANDIDATE

Solemnlyaffirmed

at(Place)

this..dayof..20.

andhis/hersignatureisaffixedinmypresence.

NotaryPublic/Principal

Address:

Officeseal:

*Deletewhichisnotapplicable.