MODEL MODEL POLYTECHNIC POLYTECHNIC POLYTECHNIC COLLEGE, COLLEGE COLLEGE,POONJ MATTAKKARA , AR (Managed by IHRD, A Govt. of Undertaking) Mattakkara.P.O,Poonjar Ayarkunnam, South P.O.,Poonjar Rosary Hill Ashramam, , Ko Dist.,Pin-686582ttayam Dist.Pin - 686 564. Ph: +9104822-209265 481 2542022 Web: mptmattakkara.ihrd.ac.inmptpoonjar.ihrd.ac.in Email: [email protected] [email protected]@gmail.com i hrd.ac.in Application for Student Veriication

Sl Particulars Details claimed by the Applicant . 1 Name of Candidate

2 Date of birth Name of University/Statutory 3 board 4 a) Course attended b) Branch :

5 a) Duration of Course b) Scheme : b) Year of 6 a) Admission No. study: Month& Year of inal semester 7 exam. 8 Register No. of examination. b)Final year a) Result of Exam. as per 9 marks / records Grade(CGPA) 1 Additional information 0 required, if any Details of documents attached 1 for 1 veriication.(attach photocopy/ scanned image with email)

Details of Institution/Agency requesting veriication Name of employer for which 1. information is requested Name of veriication 2. agency/Institution

3. Address

4. Phone No.

5. Email ID Name & designation of person 6. requesting information Email-ID to which veriication report 7. to be send Address to which veriication report 8. to be sent by registered post, if required. DD. No. ……………………………. For Rs. /- dated 9. Details of veriication fee remitted ………………………… Bank remittance on at branch Note : 1. For each candidate use separate form. Fee for multiple candidates can be paid by a single DD drawn in favor of Director/bank remittance. Fee once paid is non-refundable. 2. Processing Fee of Rs. 500/- per candidate ( Rs. 50/- extra towards postage, if report need to be sent by post) should be paid in the form of DD drawn in favor of "Principal,“Principal, ModelModel Polytechnic Polytechnic College, College, Mattakkara Poonjar" ” payable at “ SBT, Mattakkara ” or bank transfer to the SBT SB account account no. no. 570 67044890992 4362 2907 (IFSC code: SBTR0000113SBTR 0000349) ) 3. Veriication report will be forwarded within 4 working days from the date of receipt of application.

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