For Office Use Only

OPJS
UNIVERSITY Sr No. ………………………..Dated……………..
CHURU

APPLICATION FOR ISSUE/AWARD OF ORIGINAL DEGREE/DIPLOMA/CERTIFICATE

(This form is to be filled –in by the student and should be complete in all respects)
Name of Student : .....................................................................................................................................................
(in Capital Letter) Latest
Passport size
Father's Name: ..........................................................................................................................................................
Mother's Name: ....................................................................................................................................... photograph of
the candidate
Enrolment Number:...................................................................................................................................
attested by
Date of Admission:................................................................................................................................... the
Roll No.(Last Semester/Final Year Exam) :................................................................................................. candidate
Name of Course Passed :. ..............................................................................................................................
(With specialization, if any)
Permanent Address of the candidate:. ..............................................................................................................................
Street..................................................................................City/Village.............................................................................
Post.................................District.............................State.........................Pin....................................................................
STD Code.....................Ph...............................Mob............................E-mail.....................................................................
Correspondence Address of the candidate......................................................................................................................
Street..................................................................................City/Village...........................................................................
Post.................................District.............................State.........................Pin..................................................................
STD Code.....................Ph...............................Mob............................E-mail....................................................................

Name of Month & Year Roll No. Max. Marks & Document
Examination of Marks obtained enclosed
Passing
Secondary/Matriculation
Sr.Sec./ Intermediate /10+2
Diploma
Under-Garduate
Other................................
OPJS Mark-Card Ist Sem/Year
IInd Sem/Year
IIIrd Sem/Year
IVth Sem/Year
Vth Sem/Year
VIth Sem
VIIth Sem
VIIIth Sem
IXth Sem
Xth Sem
Application should write information mentioned above correctly and clearly in blue ink only. if any information
is written wrongly then the university is not responsible for the loss of information or any document or non-
issuance of original degree.
 APPLICTION FORM-2
(To be filled by the student)
(Form found incomplete in any respect will be sent back to the student, including all documents)

Name of Student :..........................................................................................................................................

(in Capital Letter)
Father's Name:...............................................................................................................................................
Mother's Name:..............................................................................................................................................
Enrolment Number:.......................................................................................................................................
Date of Admission:.......................................................................................................................................................
Roll No.(Last Semester/Final Year Exam):....................................................................................................
Correspondence Address of the Candidate...........................................................................................................
Street..................................................................................City/Village........................................................
Post.................................District.............................State.................................Pin........................................
STD Code...................Ph...............................Mob............................E-mail..................................................
Name of Examination Month & Year Roll No. For Office use only
Of Passing
Self Attested/Notarized Attached or Not
Secondary/Matriculation

Sr.Sec./ Intermediate /10+2

Diploma

Under- Garduate

Other................................

OPJS Mark-Card Ist Sem/Year

IInd Sem/Year
IIIrd Sem/Year
IVth Sem/Year
Vth Sem/Year
VIth Sem
VIIth Sem
VIIIth Sem

IXth Sem

Xth Sem
The document (s) which is/are indicated by 'x', have not been enclosed by the student Pleas submit all relevant document (s) within
15 days otherwise this request will not be processed.

Remarks (if any) : ...............................................................................................................................................................................

...................................................................................................................................................................................................................
..................................................................................................................................................................................................................

Date: ................... Authorized Signatory

Name: .......................................................................................... Name: ..........................................................................................

Address: ...................................................................................... Address: ......................................................................................
...................................................................................................... ....................................................................................................
 Details of Examination of due Paper (s) (if any)
Name of Paper with code No. Semester Month & Year of Passing Roll No.

Declaration by the Student

I............................................................(Name) hereby certify that the information furnished by me is correct to the best
of my knowledge and belief. I also certify that the copies of document duly signed and enclosed by me are true and
corrected copies of the originals. In case of any information given by me is found to be false or any certificate enclosed
is found invalid or forged, I understand that my admission will be cancelled and all fees paid will be forfeited besides
being open to other legal action.

(No. of Enclosures…………………..) Full Signature of Student

Declaration by the Exam Controller

I....................................................................(Name) hereby certify that I Have checked the information furnished in
This format with original documents (Copies whereof are enclosed herewith) and they are correct to the best of my
knowledge and belief. All the documents submitted by the student are duly signed. attested and verified by me.

Seal of Exam Controller Signature of Exam Controller

(Name in Full……………………………………….)

FOR OFFICE USE ONLY

Received Rs……………………….……..Vide Draft No…………………Date ……..….Bank Name………………………………
Towards fee for Original Degree/Diploma/Certificate.

Signature of Accounts Officer

Certificate No. ……………………………………………..Dated…………………………………………….issued to the student
By hand to (Name of Student/Guardian)……………………………………………………………………………………………..
Address……………………………………………………………………………………………………………………………….
………………………….…………………………………..………………....………………………………………………………

Sign.of Student/Guardian Sign. Of Concerned Officer