COE Form-7
North South University
Application Form for Leave Certificate
To
The Controller of Examinations
North South University
Bashundhara, Dhaka-1229
Sir,
1. I am requesting you to kindly issue me a Leave Certificate granting me leave of absence from _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ to _ _ _ _ _ _ _ _ _ _ _ _ The purpose of my leave is as follows: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
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2. For this purpose my particulars are given below (Please write in Capital letter):
a) Name of the Student (as per SSC/equivalent certificate) : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
b) Student’s ID Number : _________________________
c) Father’s Name (as per SSC/ equivalent certificate) : _________________________
d) Mother’s Name (as per SSC/equivalent certificate) : _________________________
e) Date of Birth (as per SSC/equivalent certificate) : ________________________
f) Contact number : ________________________
g) Nationality :_______________________
h) Gender [Please tick Mark (√)]: Male Female
Yours Sincerely
Signature of the student with date
3. Recommendation/ Remarks of Department Chair/ Program Director about his/ her leave (with
particular attention to examinations/important events of academic calendar):
Signature with date & Seal
For clearance of NSU Accounts For Library clearance
Signature with date & Seal: Signature with date & Seal:
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Signature of the receiving Officer with date: _ _ _ _ _ _ _ _ _ _ _ _ _ The date of delivery of the document on: _ _ _ _ _ _ _ _
Student’s Part for " Leave Certificate” (to be filled by student):
Name of the Student: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ID# _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
N.B. 1. Please enclose photocopy of your SSC/ ‘O’ level /equivalent certificate. 2. Please pay Tk. 100/- for each copy at Bank
[United Commercial Bank Limited (UCB), Bashundhara Branch, Dhaka (beside GP House)].
*The requested document will be destroyed if the applicant does not receive it within three months from the date of delivery.
Leave Certificate
