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Annexture 3 \\to OM No. C. 1173/6/615\\
of 20 June, 1975
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FORM
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\makebox[25em]{\dotfill} School/College\\
(Name and location of the Institution) 
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Certified that Mr/Miss \makebox[20em]{\dotfill}, son/daughter of \\
Mr/Ms \makebox[12em]{\dotfill}
is a student of class \makebox[12em]{\dotfill} since\footnote{Date from which continuously studying in the same class} \makebox[12em]{\dotfill}.
He/She is not in receipt of scholarships of Rs.\ \makebox[6em]{\dotfill}
per month from \makebox[6em]{\dotfill}
He/She has paid tuition fee @ Rs.\ \makebox[6em]{\dotfill} per month for the period from  \makebox[12em]{\dotfill} to
\makebox[12em]{\dotfill} as per details given below:
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\item 
 Tuition fees @ Rs.\ \makebox[12em]{\dotfill} per month
\item
Science fees @ Rs.\ \makebox[12em]{\dotfill} per month
\item
Music fees @ Rs.\ \makebox[12em]{\dotfill} per month
\item
\makebox[5em]{\dotfill} @ Rs.\ \makebox[12em]{\dotfill} per month
\item
\makebox[5em]{\dotfill} @ Rs.\ \makebox[12em]{\dotfill} per month
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It is also certified that \makebox[12em]{\dotfill}  School/College is recognised
by the educational authorities of \makebox[12em]{\dotfill} State.
(Not applicable for Government schools and schools run by Municipal/Corporations/Committees).

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\noindent Dated : 

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 Principal/Head Master/Head Mistress
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