APPLICATION FOR ISSUE OF A DUPLICATE QUALIFICATION CERTIFICATE

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Office of the Commissioner for Government Examinations, Pareeksha Bhavan, Poojappura, Thiruvananthapuram, Kerala 695012

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Applicant Information
Name of the applicant with full address:
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taÂhnemkhpw
Present address of applicant:
At]£Isâ Ct¸mgs¯ taÂhnemkw:
Name of Parent/Guardian
c£IÀ¯mhnsâ t]cv :
Date of birth: Aadhaar No: :
Phone: Mobile no: Email:

Particulars of the Examination

Particulars of the Examination cPn. \¼À hÀjhpw amkhpw ]co£m tI{µw

]co£m kw_Ôamb hnhc§Ä:
H¶mw Ahkcw/I appearance
cÊmw Ahkcw/II appearance
aq¶mw Ahkcw/III appearance etc.

Other Information
Circumstances under which a Duplicate Certificate is applied for?
Uyq¹nt¡äv kÀ«n^n¡än\v At]£n¡m\pÅ kmlNcyw Lost Damaged
(\jvSs¸SÂ/tISp]mSv kw`hn¡Â)
Has applicant applied for a duplicate certificate before? YES NO
At]£I³ CXn\pap¼v Uyq¹nt¡äv kÀ«n^n¡än\v At]£n¨n«p¶Ê¯.?

Declaration

Rm³…………………………….. ChnsS km£ys¸Sp¯p¶sXs´¶m Fsâ AÊÂ

kÀ«n^n¡äv 2018/2019 hÀj¯nse {]fbs¡SpXnbn \jvSs¸«p / tISp]mSv kw`hn¨p.

Øew (Place): At]£Isâ H¸v

XobXn (Date) (Signature of applicant)
CERTIFICATE OF THE HEAD OF THE SCHOOL FROM WHICH THE APPLICANT WAS PRESENTED FOR THE EXAMINATION FOR
THE FIRST TIME

Rm³ ChnsS km£ys¸Sp¯p¶sXs´¶m Fsâ Adnhpw hnizkvXXtbmSpw IqSn

\ÂInb Cu At]£Isâ AÊ kÀ«n^n¡äv 2018/2019 hÀj¯nse {]fbs¡SpXnbnÂXncn¨p
In«m¯ hn[¯n \jvSs¸«ncn¡p¶p/ tISp]mSpIÄ kw`hn¨ncn¡p¶p. At]£Isâ apIfnÂ
]dªncn¡p¶ hnhc§Ä Rm³ hniZambn ]cntim[n¡pIbpw icnbmsW¶v IsʯpIbpw
sNbvXp. AXn\m Cu At]£I\v Uyq¹nt¡äv kÀ«n^n¡äv \ÂIWsa¶v Xmev]cys¸Sp¶p..

Name of If SSLC,
Register If SSLC,
Examination Name of applicant as per Year of registration
Number Admission no
(SSLC/THSLC etc) adminition register

slUvamÌÀ/Headmaster
Øew (Place): Name of School with Post office
XobXn (Date) and Educational District
(office Seal)