APPLICATION FOR THE ISSUE OF A DUPLICATE S.S.C. (X CLASS RECORD BOOK) Note : The application alongwith the required documents should be sent to the Secretary to the Commissioner for Government Examinations, Chapel Road, A.P.Hyderabad-500 001 through the Head Master where the candidates last studied. 1. Name of the Applicant (in block letters) 2. Address of the Applicant (to be given clearly) 3. Father's Name 4. Date of Birth 5. Place of Birth 6. School where the applicant last stud ied 7. Serial No. of Original S.S.C 8. Number of times the applicant appeared for the S.S.C Public Examination, with the month and year of examination and register No. assigned to each appearance (Correct particulars should be given). 9. Detailed circumstances under which the Application for the issue of duplicate S.S.C Is made. (Circumstances should be clearly Stated to be supported by documentary Evidence, if any, since the particulars of loss are to be furnished will be published in the Gazette). 10. Whether an affidavit regarding the loss of The Original S.S.C, obtained from a Munsiff/First class Judicial Magistrate is attached. 11. Whether the challan for Rs. 50/- towards the Fee for obtaining a duplicate S.S.C is enclosed (Name of the Government Treasury and No. and Date of the Challan to be mentioned). ____________________________________ 0202-Education, Sports Arts and Culture 01-General Education 12. Head of Account : 102-Secondary Education 01-Examination Fee 02-Other Fee 13. Whether the S.S.C has at any time been suspended or Cancelled. ____________________________________ 14. Whether the candidate has at any time been debarred for appearing for the S.S.C Public Examination due to resorting to malpractice, if so, definite particulars may be furnished. ____________________________________ 15. Marks of identification (as per the school record and Particulars entered in the original S.S.C) ____________________________________ DECLARATION I solemnly declare that the particulars furnished above are true to the best of my knowledge and behalf. PHOTO Candidate's Photo Attested byStation______________ Headmaster Date________________ Signature of the Candidate. Note: The furnishing of inaccurate or false particulars will be entail of withholding of the duplicate certificate and in the case of the false particulars, disciplinary action will be taken such as may be called for or deemed fit by the Commissioner for Government Examinations. IDENTIFICATION CERTIFICATE OF THE HEADMASTER I certify that the above particulars furnished by the candidate have been verified and found correct with reference to the records of the school and the applicant. Sri______________________________(name to be given) is the same identical person to whom S.S.C was originally issued and that the issue of duplicate S.S.C to the candidate is recommended. Station....... Signature of the Headmaster With School Stamp. Date:........ . ..200 Note: The following certificates should be sent alongwith the application without fail. 1. Treasury Challan for Rs.50/-remitted to the Head of Account given in the column 12 supras. 2. An affidavit on a stamp paper worth Rs.10/-to be attested by I Class Judicial Magistrate. Designation stamp of the First Class Judicial Magistrate should be affixed. 3. A declaration by the candidate regarding the suspension or cancellation of his certificate previously by the competent authority. (to be attested by the Head of the Institution concerned). 4. True extract of the first page of the Original S.S.C (it will be issued by the Headmaster) 5. True extract of the Original Secondary School Certificate (it will be issued by the Headmaster). 6. True extract of the Admission Register (with marks of Identification) (it will be issued by the Headmaster) Note II: If the spoiled S.S.C is available or in case many pieces of its are available may be send to this office alongwith the application. 7. Certificate issued by a Sub-Inspector of Police or a Certificate issued by a Deputy Tahsildar as the case may be ________________________as per column 9 Supra. PROFORMA An affidavit on a stamp paper worth of Rs.10/- (to be attested by First Class Judicial Magistrate) AFFIDAVIT IN THE PRESCRIBED PROFORMA. A F F I D A V I T I,___________________________________ Son/Daughter of ___________________________ ___________________ Age _______________ Occupation _____________________________ ____________________ Resident of ____________________________ on solemn oath and affirmation state as under: 1. That I have appeared for the Secondary School Certificate Public Examination held in the month of March/October, 200 . with Register No.____________________________ through __________________________ Secondary School _____________________________ 2. That the Original S.S.C which was issued to me by the Board of Secondary Education has been lost be me and inspite of my best efforts I am unable to trace it and it is lost Beyond recovery. In case if it is traced in future I shall submit it to the Board of Secondary Education for cancellation. 3. That I am in need for a duplicate copy of the said Certificate for which purpose I am hereby making this declaration as required by the Secretary, Board of Secondary Education. "SWORN FOR ME". OFFICE SEAL FIRST CLASS JUDICIAL DEPONENT. MAGISTRATE. D E C L A R A T I O N I, _______________________________Son/Daughter of _______________________________ ________________________Aged_______________Resident of House No.______________________ ________________________student of ___________________________________________________ school hereby declare that my S.S.C bearing Sl.No.__________________Roll No._________________ of year ______________________________ has neither been cancelled nor suspended at any time by the competent authority nor I was debarred from appearing for the S.S.C Public Examination at any time due to resorting malpractice etc., by the competent authority. Signature of the Applicant //Attested// Signature of the Headmaster with School Stamp.
