SAMBALPUR UNIVERSITY

JYOTI VIHAR
758019 -
FORM OF APPTICATION FOR ISSUE OF MIGRATION CERTIFICATE
[To be filled by the student concerned]
From:

IName in fullwith complete address]

To,
The Registrar,
Sambalpur University
JyotiVihar, Burla

Throu8hthePrincipal,-colle8eonlyforRegular5tudent
sir,
I would request you to kindly issue a Migration certificate in my favour, as I intend to ioin the
_University for my further studies.
I passed/failed at the Examination of the Sambalpur
University held in the month of with Roll No. from
the College or lam at present reading
tn class in College, P,G. Department.

I passed/failed at the Examination of the

Sambalpur University held in the month of with Roll No.
as a Non Collegiate Candidate.

I have paid a fee of Rs. 2ool- I Rs.250/- (Rupees Two hundred & Two hundred fifty) only in the
shape of B.D./University Cash Receipt No. Dated

ln the circumstances, I request that the Migration certificate prayed for may kindly be issued to
me at your earlie5t convenience.

At the first instance, I registered my name in this University as a regular student through
colle gewith Registration number
(Enclose Registration Card in Original).

(Please leave tick mark Where ever applicable)

.:. ldeclare that my migration certificate will be collected by me ! or through ay eost !
.:. lalso declare that, in case I am unable to collect, then lauthorize to the following person to collect
it and it will be completely my respon5ibility.
Parents E spouse E or c/o E Name

Address-
(ln all the above cases proper ldentity proofs need to be submitted and a proper marriage lD proof
in case of spouse have to submit).

Authorization letter will not be considered after submission of miBration form in the University.

Attested
Signature of the Gazetted Officer
(with Office Seal) yours faithfully,
(tor Non-collegiate candidates only)

Signoture in full
N.B.: Please strike out the words not required Date
 SAMBALPUR UNIVERSITY
(lnformation required for issue of Migration Certificate)
(To be filled by the institution recommending the application)

1. Name of the college

(ln Ca pita I Letters)

2. Name of student
a student of the institution state the
3 Examination passed with year and Roll No or if he/she is still
class in which he/she is reading

4 WhetherthefeeofRs.l0O/-hasbeenpaidtotheUniversitydirectorcreditedtotheUniverslly
(Receipt should be attached)
account in state Bank of lndia, lyoti vihar or uco Bank, A. Katapali

5. Date of birth as in the College Admission Register

Date of {irst Admission to college uncer the unive|sity

after p2s3in6 the Matricu lation, H.5.C, or

any other Exam ination

7. Registered Number as a student of University'
8. Date of leaving the College
9. Conduct and character of the student during his/her
College career

Certificate
10. opinion of the Principal as to the University's granting the application a Migration

the student wants to take in the University he/she wants

to join
11. Degree or course

Memo No. Dated

Vihar' and Burla together the application
Forwarded to the Registrar, Sambalpur University' Jyoti
ln

original for necessarY action.

PRINCIPAL
College
(v'rith Official Seal)

N.B.
before submitting it to the principal' H O'D''
1 Applicants are advised to go through the instruction
only)'
Gazetted Officer (ln case of non-collegiate candidates
the fees must be remitted in shape of Bank
2 Money order, Postal order will not be accepted'
Vihar or cash in the University cash counter'
Draft credited to UCO bank, A Katapali, S B'l', Jyoti
The B.D. Cash receipt must be attached to the
application form'
be attended to and no correspondence
will be '
3 Application, incomplete in any manner will not
initiated in the matter.
 INSTRUCTION FOR ISSUE OF MIGRATION CERTIFICATE

1. (a) Regular student intending to obtain a Migration Certificate from this University should
apply for the same through the Head of the lnstitution they last studied under the University
otherwise the certificate cannot be issued to them.

(b) Non collegiate students who not attended the college under the University be
registered the names as students of this University, should submit their application in this
form for issue of Migration Certificate direct to the University with an attestation by a
Gazetted Officer.

2. The prescribed fee of Rs.200/- only is to be remitted to the Comptroller of Finance, Sambalpur
University to be drawn in State Ba nk of lndia, Jyoti Vihar / United Commercial Bank, A. Katapa li
/ University Cash Receipt / Bank Challan.
3. The requisite fee as stated above must be paid in advance

4. Student intending to obtain duplicate Migration Certificate, in case the originalone is lost or
destroyed should apply on payment of usual fees in the prescribed application form along
with the Court Affidavit.

5. Any student who does not join another University after obtaining Migration Certificate from
this University and if he/she joins this University again should surrender the Migration
Certificate to the University through the principalofthe college which he/she joins along with
usual registration and recognition fees.

6. The registration receipt in original must be surrendered along with this application for issue
of Migration Certificate in case of one is out or destroyed he/she should apply along with
Court Affidavit on payment of usual fees of Rs. 300/- only.

7. For any other information not provided for in the above items a reference may be made to
the Registrar in writing.

8. Any student, who wants to receive the Migration Certificate in person, should show his/her
proper identification (Migration Certificate is given to candidates) himself only.

9. Any student, who wants to obtain the Migration Certificate by Post may remit a sum of Rs
50/- extend rate towards postal charges over and above the prescribed fee of Rs. 200/- only.

10. lo.Students of MBB5, M.D., M.S., BAMs, BHMS, B. Pharma applying for Migration Certificate
should submit a xerox copy of Provisional / Original Certificate.

REGISTRAR