FORM - G
GOVERNMENT OF GOA
BOARD OF TECHNICAL EDUCATION
Alto, Porvorim - Goa
APPLICATION FOR ISSUE OF DUPLICATE DIPLOMA CERTIFICATE
1. Name of the Student:______________________________________________
2. Address: __________________________________________________________
3. Telephone No.: __________________
4. Institute where the student was studying: ___________________________
__________________________________________________________________
5. Diploma Programme undergone: _________________________________
6. Enroll. No.: ________________
7. Month & year of passing:________________________
8. Is the Diploma certificate spoils spoiled/lost: _______________
9. If spoiled, attach spoiled Diploma Certificate.
10.Copies of document attached
a) Copies of Mark sheets of all semesters
b) Affidavit as per format supplied.
Date: Signature of the candidate
Forwarding remarks from Institute:
Date: Seal Signature of the Principal
FOR OFFICE PURPOSE ONLY
Details of payment of Fees
Rs.500/- + Search fee.
Receipt No:
Date: Cashier
Duplicate diploma issued on
Signature
SAMPLE AFFIDAVIT
(TO BE SWORN ON NON-JUDICIAL STAMP PAPER FOR ISSUE OF DUPLICATE DIPLOMA)
I _______________________________________________son/daughter of
_______________________________aged _______ year, married/unmarried, resident of __________________________________________________________, do hereby make solemn affirmation and state as under:
1. I say that I was a student of ________(Institute Name)______________ for a period from ___________ to ___________ and completed my diploma ___________(Programme Name)_________________ with enrolment No.___________
2. I say that I was issued by Board of Technical Education diploma certificate bearing No.________dated______________, which is misplaced/lost/damaged.
3. I say that the said diploma certificate is misplaced/lost__________(circumstances of loss)_____________________.
4. I say that I have lodged a police complaint on the loss and in spite of my best efforts the certificate could not be traced/located.
5. I say that I am in need of a duplicate copy of the said diploma certificate for the purpose of personal records.
6. I say that the affidavit is sworn in order to produce the same before the concerned authorities for the purpose of obtaining duplicate diploma certificate.
7. I say that I undertake to furnish the original certificate to the college authorities/Board of Technical Education if the same is found
subsequently.
8. I say that I indemnify the college authorities against any loss, damage, court proceedings litigation, claims, demand etc arising from the issue of the duplicate certificate.
9. I say that whatever I have stated above is true to my own knowledge, and the same hide nothing and no part of it is false.
Solemnly affirmed at _____________ on this___________ day of______20___
(DEPONENT)