Download application form - Dibrugarh University

Merit Abstract(To be filled by the candidate)Name of the course based on which admissionis sought ______________________________________________________________________Total Marks Secured ________ out of_________PC of Marks _________Division_________Other qualifications if any (e.g. GATE/NET)with percentage/percentile ________________________________________________________SUMMARY SHEET OFAPPLICATIONFOR ADMISSIONNo.Affix passportsizephotographhereDepartment into which Admission is sought1. Applicant's Name in Full (BLOCK CAPITALS)Surname Mr./Miss/Mrs. Name2. Whether hostel accommodation required(Please tick appropriate box)Yes No3. Date of Birth 4. RegistrationDate Month Year No. Year University5. (a) Caste (Please tick appropriate box) (b) Sub-CasteSC ST(P) ST(H) OBC MOBC Others6. Particulars of Father/Guardian/Husband (Relation) _________________________________Name _________________________________________ Phone No. ______________(R)______________(M)_______________________________________________e-mail ID__________________________________Address _________________________________________ P. O. ______________________________________District _________________________________________ State ________________ Pin__________________7. Permanent Home Address _______________________________________________________________________P. O.____________________________________________ District ______________ Pin___________________8. Particulars of Local Guardian : (Relation)__________________________________Name__________________________________________ Phone No. ______________(R)______________(M)______________________________________________e-mail ID__________________________________Address ________________________________________ P. O.__________________ Pin_________________9. Blood Group _____________________________________10. Examination Passed (Beginning from H. S. L. C. or equivalent)Name of Examination Name of University/Board/ Roll Year of Class % ofCouncil No. Passing Division Marks11. If employed, give particulars hereDate _________________Student No. _________________Admitted _____________________________Head Department ofSignature & Date _______________________(For Office Use Only)Signature of ApplicantDate of Admission ___________________Dy. Registrar (Academic)Dibrugarh UniversityDate ______________

Application For AdmissionNo.into the Post-Graduate/Under-Graduate/Degree/Diploma/ Certificate CoursesMerit Abstract(To be filled by the candidate)Name of the course based on which admissionis sought ______________________________________________________________________Total Marks Secured__________ out of_______PC of Marks _________Division_________Other qualifications if any (e.g. GATE/NET)with percentage/percentile ________________________________________________________1. Applicant's Name in Full (BLOCK CAPITALS)To be submitted to the Head of the Departmentconcerned on or before :Dibrugarh - 786 004[Read Information Brochure carefully before filling up the form]Course :Department :Session :Affix passportsizephotographhereSurname Mr./ Miss. /Mrs. Name2. Father's Name : _______________________________________________________________________________3. Mother's Name : ______________________________________________________________________________4. Father's/Guardian's (if father is deceased / Expired)Name, Occupation and Address :5. Address for correspondence :Name _____________________________________ Occupation ______________________Address _______________________________________________________________________________________________________________ Pin _______________________________________________________________________________________________________________________________________________________________________________________________________________________ Pin ___________________________Phone__________________(R)_________________(Mobile) e-mail____________________6. Date of Birth : Day Month Year 7. Nationality : _________________(Attach H. S. L. C. Certificate)8. Sex : Male Female 9. Marital Status : Married Unmarried10. Blood Group ______________________11. Community : SC ST(P) ST(H) OBC MOBC General 12. Religion : ______________(Attach certificate from competent authority)13. Where to reside ? At home University Hostel Out side14. Are you employed ? Yes No(If yes, submit no objection certificate from the employer)15. Are you on deputation ? Yes No(If yes, name of the School/College/Department/Organisation : _____________________________________________).16. Name and Registration Number of the University/Board/Institution where registered last :____________________________________________________________

17. Educational Qualification starting from H. S. L. C. or equivalent :(Attach attested copies of marksheets and certificates of all examinations)Examination Board/Council/Year of Div./ PercentagePassed UniversityRoll No.Passing Class of Marks10thstandard10+2Subjects Taken10+2+318. Academic distinction/medals/ _______________________________________________________________prizes/scholarships, if any(Attach certificate)_______________________________________________________________19. Any Extracurricular Activities(Mention the activities and furnish testimonials) _________________________________________________________20. Are you differently abled (physically handicapped) ? Yes No(If yes, attach certificate from the competent authority)21. Are you undergoing any course of study at present ? If yes, give details.UNDERTAKINGI declare that, if admitted, I shall abide by the Statutes, Ordinances, Rules, Regulations, Orders etc. of the DibrugarhUniversity that will be in force from time to time. I submit myself to the disciplinary jurisdiction of the Vice-chancellor and otherauthorities of the University who may be vested with such powers under the Act, Statutes, Ordinances, Orders and the Rulesthat have been framed thereunder by the University.I also declare that the information given above are true and complete to the best of my knowledge and belief andif any of them is found to be incorrect, my admission shall be liable to be cancelled and I shall be liable to such other disciplinaryaction as may be decided upon by the University.Date :Full signature of the applicantFor Office Use OnlySelected Provisionally Under1. General Merit List2. SC/ ST Quota Remarks :3. Reserved QuotaRejectedChairman, Admission Committee Head of the Department Dy. Registrar (Academic)

Received an application bearingNo. :From _____________________________________________For admission in the Subject_________________________For the session ___________Date ____________________Signature of the receiverReceived an application bearing No. :From _____________________________________________________For admission in the Subject ___________________________________For the session _____________________________________________Date ____________________Signature of the receiverN.B . : The candidate is to enter the name and other relevant particulars in this receipt.Received an application bearingNo. :From _____________________________________________For admission in the Subject_________________________For the session ___________Date ____________________Signature of the receiverReceived an application bearing No. :From _____________________________________________________For admission in the Subject ___________________________________For the session _____________________________________________Date ____________________Signature of the receiverN.B . : The candidate is to enter the name and other relevant particulars in this receipt.Received an application bearingNo. :From _____________________________________________For admission in the Subject_________________________For the session ___________Date ____________________Signature of the receiverReceived an application bearing No. :From _____________________________________________________For admission in the Subject ___________________________________For the session _____________________________________________Date ____________________Signature of the receiverN.B . : The candidate is to enter the name and other relevant particulars in this receipt.Received an application bearingNo. :From _____________________________________________For admission in the Subject_________________________For the session ___________Date ____________________Signature of the receiverReceived an application bearing No. :From _____________________________________________________For admission in the Subject ___________________________________For the session _____________________________________________Date ____________________Signature of the receiverN.B . : The candidate is to enter the name and other relevant particulars in this receipt.

DIBRUGARH UNIVERSITYAPPLICATION FORM FOR HOSTEL ACCOMMODATION FOR THE SESSION_____________________Research Scholar M. Phil Scholar Teacher Fel. Semester : I II III IV(Please tick in appropriate Box)1. Name in full ( In block Capitals) Mr. / Miss/ Mrs. _______________________________________________________2. a) Department in to which admitted_______________________________________________________________b) Session _____________________________ (c) Receipt No. ________________________Dt. ______________3. Father / Legal guardian's Name Mr. /Miss/ Mrs. _______________________________________________________Home address Town / Village_______________________________________ occupation_____________________P. O. __________________________ District_________________________ State_______________________4. Local guardian's address ________________________________________________________________________Occupation_______________________________________________ Phone No.__________________________5. a) Caste (Please tick in appropiate Box)S.C. S.T. O. B. C. Other Phy. handi. (b) Sub caste ___________________6. Degree Examination passedName of Name of Year of passing College in whichExamination University with Roll No. studied7. Marks secured in the examinationExamination Full Marks P. C. of Result/marks Secured marks Position1. DegreeExamination (major)2. DegreeExamination (pass)3. M.A./ M.Sc. /M.Com.DECLARATION : I certify that the particulars given above are correct. I agree to abide by all rules and regulations of theHostel and to pay all my dues regularly.Date______________________Forwarded after verification of all particulars including marks sheet.* Signature of the applicantDate__________________*Head of the Department____________________(For Office Use Only)Position of student in the merit of the applicant ____________________________________________________________Provisionally selected for admission in to __________________________________________________________ HostelChairmanH. A. CommitteeAlloted No.___________________________Section OfficerS. W. Section.Deputy Registrar (admn.)Dibrugarh University