1. No category

Joint Admission Counselling, Delhi-2014
Sr. No.__________
REQUEST TO WITHDRAW CERTIFICATES PROVISIONALLY SUBMITTED AT TIME OF COUNCELLING
Name of Candidate: (Mr/Ms): _________________________________________________
Address: __________________________________________ PIN Code: ______________________
Tele. No. (with STD code) _____________Mobile No. _____________________________________
Email Id:___________ JEE Roll No. __________________JEE Rank ___________________________
Category (SC/ST/OBC/Def/PH/Kashmiri Migrant/SG/TP)_________________________________
Admission Taken________________Branch_______________Institute/University Roll. No._____
Certificate Submitted:
1. The original of Date of Birth certificate as indicated in High School or equivalent
examination i.e. Class X..
2. The original copy of marks sheet of the qualifying examination i.e. Class XII or
equivalent.
3. The original certificate and attested copy for the reserved category, if other than the
General Category.
4. Any other Certificate_______________________________________________
(Please enclose the copy of your Id. Card of University/Institute, where the admission
has been taken)
Date:
Receiving Acknowledge:
Signature of Candidate
I ________________JEE Roll. No. ______________________Rank_______________
Received with thanks the following certificate on ________________________(Date)
Please Tick (√)
1. The original of Date of Birth certificate as indicated in High School or equivalent
examination i.e. Class X.
( )
2. The original copy of marks sheet of the qualifying examination i.e. Class XII or
equivalent. .
( )
3. The original certificate and attested copy for the reserved category, if other than the
General Category. .
( )
4. Any other Certificate_______________________________________________
Total no. of Certificate Received: ____________________________
Undertaking:
I understand that the certificate returned to me are only provisionally, if
University/Institute further required any certificate during course of study, i am
bound to show or deposit as and when asked to do so. I will obey all rules and
regulations of University/Institute, where i have taken admission.
Date:
Certificate Disbursing Officer
Signature of Candidate
Chairman, JAC-2014