FMS 4

FACULTY OF MANAGEMENT SCIENCESAddress: Tel:

A-Block, ML Sultan Campus (031) 373 5441

APPLICATION FOR STATEMENT IN LIEU OF ORIGINAL CERTIFICATE/DIPLOMA/DEGREE An Application Fee is Applicable. Refer to Fee Rule B 16 for Current Fee

Note: Only One (I) ORIGINAL statement in Lieu of Certificate/Diploma Degree will be issued per Student per Qualification - There will be a waiting period of approximately three weeks *(for qualifications prior to 1990, the waiting period will be longer)

The following documents must be submitted with this application: (Please mark with a )

1. Signed and sworn DUT Affidavit Yes No

2. Copy of ID Yes No

3. Proof of Payment Yes No

STUDENT DETAILS (to be completed by applicant)

Student Number

Surname First Name/s

Identity Number Passport Number (International Student)

Postal Address

Postal Code

Contact Number/s Home Work Cell

Email Address

Full Name of Qualification

Qualification Code

Signature of Student Date

FACULTY OFFICE

Blank Collected by Date

Verified by Faculty Officer Date

Date

ACADEMIC DATA AND STUDENT RECORDS

No. of Original Certificate Date of Issue

Checked by Status Changed

STUDENT ADMINISTRATION/ FACULTY OFFICE

Checked by Date Stock No

Statement printed by Date

Routing: Student -→ Finance → Faculty Office -→ Academic Data -→ Student Administration -→ Faculty Office

Printed Copy Collected by

Arrear Fees checked Yes No

Spoilt Certificate No

AFFIDAVIT

(Your ID Book must be produced when completing this Affidavit)

I,….................................................................,……(ID/Passport Number)..………………..……… the undersigned, do hereby state that the reason(s) for which I wish to apply for a statement in lieu

of my original certificate from the Durban University of Technology is/are the following:

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...………………………………. ...………………………………. SIGNATURE OF DEPONENT DATE

………………………………… COMMISSIONER OF

OATHS (External to DUT)

I hereby certify that the Deponent has acknowledged that he/she knows and understands the contents of this affidavit, which was signed and sworn

to before me at ..................... on this ........... day of ..............2...........

STAMP