STUDENT STATUS CERTIFICATE
 A to Z 650 MB software on CD :STUDENT STATUS CERTIFICATE
  Rs 130 CD post free in place of Rs.200 with Postal charge Other software listed on downloads.html for Rs.200/-
 
Mr/Ms (First Name)>>>>>>
(Middle Name) >>>> (Last Name)>:
Institute\University or college  Name >>>

 
Category>>>> Research Student PG student Other #
Less than one year Between 1 and 2 years More than 2 years
Period of stay in the institute:>>>>>
Address (Home/Office) :
 
City :>>>>>>>
Pincode :>>>>
Telephone of Dept Head :>>>>
(Home) (Office) : (Fax) :
Your E-mail :>>>> Date of birth DayMonthYear
Amount :>>>> Rs. MO to author acceptable MO Receipt details
Cheque/ Demand Draft No. :>>>>   in favour of Prakash P Roday on SBI, 1143  Branch,   branch SAGAR 470 003, SAGAR , M.P., India.Rs.25 exchange on cheques extra
from Bank :>>>>>

 Signature of Head of Dept \ College Principal with seal or stamp:>>>
 		 Signature of the student requesting postal charges remission  >>>>>>>

 
# Check this if you are an undergraduate, or have an impediment of speech or limbs but need not give any details.
Please print this form (The table borders -not background- will be printed by default) and mail it (with your DD , Sagar and made payable to payable to the addressae drawn on State Bank of India, 1143 branch for Rs. 130=00 ) to:
Prakash P Roday,                                    
Department of Applied Geology,               
 Dr H S Gour University,                  
SAGAR 470 003, M.P., India

PLEASE CLICK THE IMAGE AT TOP LEFT TO RETURN TO THE PAGE FROM WHICH YOU ARRIVED HERE. (You may omit the images in top frame while printing).
                Click the image to Print this page