Application for student leaving without completing the course
For Office Use Only
PRN /PDVBE NO
Paid Amount
Receipt No & Date
T.C/L.C . No & issue date
Application File No
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To,
The Principal
Dr.Vithalrao Vikhe Patil College of Engineering.
Vilad Ghat . Ahmednagar
Subject : Request to issue college leaving certificate & return original document’s.
Sir,
I Mr./Ms. _________________________________had taken admission to four year Bachelor of
Engineering Degree course in (F.E/DSE/ME/SE/T.E) _________ Branch _______________ in
Dr.Vithalrao Vikhe Patil College of Engineering,Ahmednagar for the academic year 20__ 20__I
Could not successfully completed the said degree course in the year because of following reason.
1
2
Further, I do not intend to continue my further studies in engineering course. I, therefore request you to
kindly issue me the college Leaving Certificate.
I am also submitted herewith the written consent from my presents for cancellation of my admission
from this college.
Your,s Faithfully
Name & Signature ( )
Enclosures:-
1. Xerox copy of the marks list 2. Xerox copies of the receipts
3. One Passport size Photo. 4. Identity card
CLEARANCE /NO DUES DETAILS
Sr.No. Department Remarks ( Due’s if any) Signatute with initial
Yes /No & rubber stamp
01 Concerned HOD
Civil/Mech/E&TC/Elec./I.T
02. Workship (only Mech Students)
03. Account
04. Library
05. Hostel A,B & Kaveri
06. Exam Section
07. Scholarship Section
Only catergory students( if account dues)
5. Remark of the in charge Admission: _______________________________________
6. Consent of the parents :_________________________________________
Please issue Leaving Certificate
Received the following documents
Date: Name & Signature ( )
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Principal
Dr.Vithalrao Vikhe Patil College of Engineering.
Ahmednagar
Note: L.C. will be issued after 15 days after submission of this application.
