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Adobe Scan 10-May-2024

The document is an application form for a student to request certificates from the National Institute of Technology Karnataka. It requests basic information like name, date of birth, program details, and contact information to process the certificate request.

Uploaded by

ACHINTHYA RAJKUMAR
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12 views1 page

Adobe Scan 10-May-2024

The document is an application form for a student to request certificates from the National Institute of Technology Karnataka. It requests basic information like name, date of birth, program details, and contact information to process the certificate request.

Uploaded by

ACHINTHYA RAJKUMAR
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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NATIONAL IN8TITUTE OF TECHNOLOGY KARNATAKA, 8URATHKAL,

P.0. BRINIVASNAGAR, MANGALURU- 678 023


Form of Appllcation for Isaues of certifMcate
1 Name of the Canddate
(Block Letters )
ACisIN THYA V RATkyMAR
|A per Roll List)

3
2 Rrquest for Certificate
Reason
Course Com plabon Carsiste
4 Date of Dirth nhAuguakais. Gender:- ale Pemale
(Ticlk)
6 Category :8C 8T OBC
7 Detalls of the
Programme
Course :BEch i) Branch:
Mochenical Gminszday
n) Guide Name
NA .i) Reg/Roll No. Dleala 2a Meo5
(Por Roeearch Bcholar)
y Semester/Year Sam 8 Yaor lý vi) Date/Year of Admision: 18 No o2o
w) CGPA OREAged 653(upto 7hganiI) Landine / Moble No.:8628631911
8 Month &Yea of passing
(For Passed out student)
9 Permanent Adres(Block Leters) FLAT Do 34 TRELS SouTA, lor
L8S ARast RoAD VAQAPALANT, CHEANAT Pin No. oso26
10 For NOC (Mentlon Reason with Place of visit along with duratlon):

Dd lo "Mab Signature of the Candidate with date.


(Fonáarding t Head of Department)
The Application for the issue of certificates applled by the student is being forwarded to Dean (Academic).

Dated: Slgnature of the HOD.

(Tobe filled by the Academie Sectlon)


Certified that above entires made by the Applicant are correct and as per our office Record and the
certificate/s can be issued to him/ her applled for.

Dated: Asslstant Registrar (Academic).

Dated: Dean (Academle).

Dated: (APPROVAL) DIRECTOR

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