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Leaving Certificate Form (Course Completed Students 2017-18)
GOVERNMENT POLYTECHNIC, AHMEDNAGAR.
Course Code with Roll No. (For eg TYCE-21) *
Academic Year *
Enrollment Number *
Name of candidate Fill in Capital Letters Only (as per 10th /SSC markshit) *
Gender *
Religion/Caste (as per previous Leaving Certificate Fill in Capital Letters Only for eg HINDU-MARATHA) *
Nationality(Tick Only if it is mentioned on previous Leaving Certificate) *
Date of Birth in Figures(as per previous Leaving Certificate For eg 01/01/1999) *
MM
/
DD
/
YYYY
Date of Birth in words (Fill in Capital Letters Only) *
Place of Birth (as per 10th/SSC Leaving Certificate Fill in Capital Letters Only) *
School/Institute Last Attended (10th/12th/ITI) before admitting GPAN (Fill in Capital Letters Only) *
Date of Admission (as per First Year/Diret Second Year Admission Receipt) *
MM
/
DD
/
YYYY
Conduct *
Progress *
Course and Year in which studying *
Reason for Leaving *
Self Mobile Number *
Documents attached (Xerox Copies) *
Required
Sign of Student *
Required
No dues Sign ( Compulsory to tick all options.) *
Required
Facilty Taken *
Student Section for facility *
Required
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