Form No. Ex- 47 Assam Higher Secondary Education Counc! (GUWAHATI - 781 021 APPLICATION FORMFOK ORIGINAL CERTIFICATES (RULES OVERLEAF) To The Secretary ‘Application dated ‘Assam Higher Secondary Education Council Date of receipt Bamunimaidam, Guwahati - 781021 ‘Supdt. ‘Through the Principal, so sesniei sss. College 1 H.S. School. Sir | have the’honour to request you kindly to issue me a Provisional/Original Certificate. My particulars are given below +. Name of the candidate (in Block Letters) 2. AHSEC Registration Number eee ee Steerer Father's Name in full 4. Home Address : Clo Vill Town 3 Po. PIN Dist ‘Examination Name ofthe Yearof | Exam Rol Diva, Name ofthe Passed Board/CouneilUniversity | _Exam. &No. Institution HSLC HSSLC. STREAM : ARTS/ SCIENCE COMMERCE/ VOCATIONAL (Please tick) Fee Paid PaymentreceiptNo. | BankDraft | Assam Co-operative Apex Bank Ltd. Amount Rs. and date No. & date Challan No. & Date DECLARATION BY THE APPLICANT | declare that the above particulars are true to the best of my knowledge and belief. If any particular(s) is/are found to be false, | shall be liable to action as deem fit. Full Signature of the applicant RECOMMENDATION OF THE PRINCIPAL This is to certify that Sri/Smti..... NO. sense of... student of CollegelH.S. School passed the H.S. Examination and was placed in Registration under Roll... No. ision as Regualr/IPINIP candidate. Memo No. Date Place Official Seal ‘Signature of the Principat with seal (Principal's Name in full (in Block letters)