GITAM UNIVERSITY

DIRECTORATE OF EVALUATION
Separate Application is to be submitted for each certificate
Grade Card

*
PCMG

Original

Application Form for

**
Migration
Rank Card
Duplicate

CGPA to % Conversion ***

****

In-Person

By Post

(Postal Charges: Rs.75/- Extra)

1. Name of the Candidate

(as in SSC in Capital Letters)
Fathers Name in full

Mothers Name in full

2. Parents

3. Postal Address

4. Phone No.

Mobile No:

Land Line
(with STD Code):

5. e-mail Id
PARTICULARS OF THE QUALIFYING EXAMINATION

6. Program
Particulars
7. Campus

Program

Branch

Period of study

Visakhapatnam

Hyderabad

Regd. No.

8. Registered No
& Year of Passing

Month & Year of passing

9. Fee Paid : Fee can be paid either through Challan to Account No.35017, Union Bank of India,
GITAM Campus Branch, Visakhapatnam-530 045 or through DD in favour of GITAM University
payable at Visakhapatnam.
Challan No. / D.D.No. :

Date :

Amount :

In words :

Bank :

Place:
Date:

Signature of the Candidate

NO DUES CERTIFICATE
(Only for candidates applying for PC/PCMG)

Certified that the candidate has NO DUES to the Institution.

Signature of the Head of the Department

(Stamp of the Department)

Signature of the Principal/Director

(Stamp of the Institution)

Received the Certificate:

Date:

Signature of the Candidate

* Provisional cum Consolidated

Memorandum of Grades (PCMG) : Enclose a photocopy of SSC or equivalent.

** Migration Certificate
: Enclose a photocopy of TC.
*** CGPA to % Conversion
: Enclose photocopies of SSC or equivalent and Last Sem./Trim. Grade Card.
**** Duplicate Certificates
: Enclose photocopies of i) Original Certificate and ii) Affidavit as in AnnexureII.