Campus : Ghari, Awang Leikai,
Imphal West, Manipur - 795140
KNOWLEDGE INNOVATION OUTREACH
Recent passport
size photograph.
APPLICATION FOR ISSUE OF DUPLICATE CERTIFICATE The photo may
appear on final
document
Instructions:
1. Duplicate Certificate will be issued only in case of lost or destroyed irrevocably.
2. Incomplete and wrong details in application will not be entertained and no correspondence will be made in that behalf.
Enrollment No. Course
Name of the Applicant
Father’s / Husband’s Name
Mother’s Name
Complete Address for correspondence
City State Pin Code
Contact No. E-mail
Reason for applying for duplicate certificate ? Lost Destroyed Irrevocably
(Please tick the relevant option)
PAYMENT DETAILS
Normal Mode : The Certificate will be dispatched within 8 weeks from the receipt of complete application.
Enclosed transaction slip of Rs. 3,000/- per document of online transfer in the account of Asian International University, Account No-
50200097384136, IFSC Code- HDFC0006717, HDFC Bank.
Express Mode : The Certificate will be dispatched within 4 weeks from the receipt of complete application.
Enclosed transaction slip of Rs. 5,000/- per document of online transfer in the account of Asian International University, Account No-
50200097384136, IFSC Code- HDFC0006717, HDFC Bank.
DECLARATION
I hereby declare that all the information provided by me is true to best of my knowledge & belief, also all the documents submitted are true
copies of the original. I further declare that I am abided by the regulations and eligibility conditions of the University. I understand that I may
be required to furnish additional information/ document incase of requirement from the University. I also understand that my candidature or
award from the University can be withdrawn at any given point of time even after issuance, if, the information submitted by me is found to be
incorrect or counterfeited.
Date:.................................. Signature of the Applicant
MANDATORY ENCLOSURES
1. Online Transaction Fees Slip.
2. Self Attested 10th and Onwards Educational Proof.
3. Self attested photo copy of Proof of identity i.e. Aadhaar Card
4. Self attested photo copy of Copy of lost / destroyed certificate, if available
5. An Affidavit (Specimen enclosed) in original, on Non-Judicial Stamp Paper of the value as prescribed in the Domicile State of the applicant duly notarized.
To be executed on Non – judici al Stamp Paper of Rs. 100/- and to be notarized
AFFIDAVIT FOR ISSUE OF DUPLICATE CERTIFICATE
I,
Father’s Name
Mother’s Name
Resident of
Enrollment No
Course
do hereby solemnly affirm as under:
1. That I have lost my mark sheet issued from Asian International University, Imphal West, Manipur
& request the University to issue duplicate mark card.
2. I undertake that if my lost mark sheet is found, I shall return the same to the University.
3. I undertake that in case someone misuses my lost mark card, I shall be solely responsible for
the same.
Deponent
I above named deponent do hereby solemnly verify that the contents of my above affidavit are true &
correct within my knowledge & belief and nothing has been concealed.
Deponent
Verification
Signed and verified at ……………………… on this ………………… Day of Year 20………
