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a16

This document is an application form for the re-issue of an identity card at the Indian Institute of Technology (Indian School of Mines) Dhanbad. It outlines the reasons for requesting a new ID card, the required documents, and associated processing charges. Additionally, it includes a format for an affidavit in case of a lost ID card, which must be notarized.

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6 views

a16

This document is an application form for the re-issue of an identity card at the Indian Institute of Technology (Indian School of Mines) Dhanbad. It outlines the reasons for requesting a new ID card, the required documents, and associated processing charges. Additionally, it includes a format for an affidavit in case of a lost ID card, which must be notarized.

Uploaded by

prabidushk
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Form No: A16

INDIAN INSTITUTE OF TECHNOLOGY (INDIAN SCHOOL OF MINES) DHANBAD


OFFICE OF THE DEAN (ACADEMIC)

APPLICATION FORM FOR RE-ISSUE OF IDENTITY CARD


[Please send the duly filled-in form with enclosures to [email protected]]

1. Name of Student
2. Admission No. Department

3. Program Branch (if any)

4. Institute Email ID
5. Contact Number
Reason for this request, Documents required to be submitted and processing charges:
Please
Reason Documents to be Submitted Charges
tick
Validity expired and the prescribed The student shall be required to submit expired ID Nil
6. program duration is not over. Card along with this application.
Validity expired and the prescribed The student shall be required to submit expired ID Rs. 300/-
program duration is over. Card along with this application.
Lost ID Card Affidavit to be submitted in the enclosed format Rs. 500/-
Accidentally damaged ID Card The student shall be required to submit damaged ID Rs. 500/-
Card along with this application.
Payment Details - https://www.onlinesbi.com/sbicollect/icollecthome.htm?corpID=272342
(Select payment category: OTHER ACADEMIC FEES / FINES)
7. SBI Collect Reference No. / UTR No.
Amount Paid (in Rs.) Date of Payment DD/MM/YYYY
Encl: Please attach the following:
(i) Document as indicated in point 6.
(ii) Receipt of the Online payment.

Date:______________
(Signature of the Student)

FOR OFFICE USE ONLY

Verification:
The facts, as stated above are CORRECT/NOT CORRECT Date of Receipt of Application:
as per records available. _______________________________________
Observations, if any:
________________________________________________
Issuing Date of ID Card:
________________________________________________
_______________________________________

Date:___________ Date:___________

Signature of Dealing Assistant AR (Academic – PG)


(FORMAT FOR AFFIDAVIT TO BE SUBMITTED IN CASE OF LOSS OF ID CARD)

INR 10
Notarial/Special Adhesive Stamp

Before the Notary Public, Dhanbad


AFFIDAVIT

I …………………………………………………………………….…………... (Name of the student)

Admission Number……………………..……… Branch…………………………………..…………..

Father’s Name…………………….…………………………………………… DOB…………………

Present Address…………………………………………………………………………………………

do hereby solemnly affirm on oath and declare as follows:-

1. That, I have lost my original Institute’s Identity Card and despite of all my efforts I couldn’t trace it.
2. That, I request you to issue a Duplicate Institute’s Identity card.
3. If I find back, my original Institute’s Identity Card the duplicate ID card will be returned back to Institute.
4. That, I am swearing this affidavit to produce it before the concerned authority for issuance of Duplicate
Institute’s Identity card.

Solemnly affirmed before me Verification


By the deponent who is duly The statements made are true to my knowledge
Identified by Shri………………………. and belief. I am signing this Affidavit in Dhanbad
Advocate, Dhanbad on ______________(Date)

Dated______________________ Sign___________________
(Deponent)
Notary Public, Dhanbad
Stamp & Sign
Identified by

Advocate

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