SRM INSTITUTE OF SCIENCE AND TECHNOLOGY
(Deemed to be University u/s 3 of the UGC Act,1956)
DIRECTORATE OF DISTANCE EDUCATION
ADDRESS & NO DUES VERIFICATION
Register No : Date:
Name of the Candidate as entered in
the University records:(in Capital
Letters)
Register Number Date of
(Last Appearance) Birth
Year of Admission Month Year
Duration of the Course
Gender Male/Female/ Transgender
Name of the Degree/Diploma
Branch
Subject /Specialization
Name of the College and Year of study
Month &Year of Appearing the Final
Examinations
Mention Year or Semester pattern
Communication Address
Mobile Number
E-mail (pls. Write in Clear)
Note: Application forms will not be accepted under any circumstances if color photo is not affixed .
Office Purpose
NO Dues :
Accounts Section :
SIGNATURE OF THE STUDENT SIGNATURE OF
THE HEAD OF THE INSTITUTION