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Assam University Application Form 2015
Assam University Application Form 2015
Assam University Application Form 2015
ASSAM UNIVERSITY
SILCHAR-788 011 CACHAR (ASSAM)
SC/ST
500.00
Others
600.00
Name of Bank
Prospectus
Amount
Application fee
Nil
100.00
D.D. No.
700.00
Date
Total
500.00
* Applicants purchasing prospectus from university shall attach photocopy of the receipt along with this application form.
% of Marks secured
GENERAL INFORMATION
Campus in which admission is sought
Silchar
Diphu
UG
: _____________________________________________
PG
Integrated
Diploma
PERSONAL INFORMATION
1.
: ______________________________________________
2.
3.
Mothers Name
: ______________________________________________
4.
: ______________________________________________
5.
Male
SC
Female
ST
OBC
KASHMIRI MIGRANTS
Transgender
PWD
GEN
ANY OTHER
6.
Date of Birth
D D M M Y Y
7.
Blood Group
: ___________
* SC :: Scheduled Caste, ST :: Scheduled Tribe, OBC :: Other Backward Class, PWD :: Person
With Disabilities, GEN :: General
(ii)
8.
Nationality
_______________________________________
9.
Religion
_______________________________________
10.
11.
Permanent Address
Married
Single
Widowed
Divorced
_______________________________________
_______________________________________
_______________________________________
14.
_______________________________________
_______________________________________
15.
_______________________________________
Telephone number : __________________________
16.
Yes
No
_______________________________________
_______________________________________
17.
Yes
No
_______________________________________
18.
_______________________________________
_______________________________________
Yes
No
(iii)
19. Educational Qualifications : Please enclose self attested copies of all documents in support
of educational qualification, date of birth etc.
Examination
School /
College
Board /
Council /
University
Subjects
Year
Distinction
Division % of
Marks
High School
Higher Secondary
BA/BSc/BCom
(Pass/General)
BA/BSc/BCom
(Major/Hons)
Any other exam.
...........................
20.
21.
22.
23.
_______________________________________
Yes
No
_______________________________________
_______________________________________
Yes
No
_______________________________________
(Attach a gap certificate from the Head of the Institution you attended last or from a gazetted
officer).
(iv)
I, _______________________________________________, hereby solemnly declare on oath that the entries made by
me in the application form are true to the best of my knowledge and belief and if at any time the entries are found to be
incorrect, my admission may be cancelled and disciplinary action may be initiated against me.
Place : _______________
Date : _______________
Declaration by Guardian
I,_______________________________________________, have gone through the declaration made by my son/ daughter/
ward and agree to abide by all those declarations.
I further declare that I agree to meet all expenses in the University and/or in the hostel of my son/daughter/ward during the
period of his/her course of study. I shall compensate for any loss or damage caused by my son/daughter/ward to the
Universitys property.
23. Information for Statistical Purpose
a) Category(SC/ST/ OBC/PWD/General) ______________
b) Rural / Urban ________________________________
c) Fathers/ Mothers Annual Income ________________
d) Occupation__________________________________
________________________________
Full signature of Guardian
Place : _________________
Date : __________________
(Signature)
Chairperson, Departmental Admission Committee
ADMITTED/REGRETTED
(Signature)
(Signature)
Head of the Department
Date : ___________________
FILLED IN APPLICATION FORM MUST REACH THE UNIVERSITY BY JUNE 19, 2015
For Courses in Silchar Campus
Send by post or deliver
To,
The Head,
Department of __________________________,
Assam University, Silchar - 788 011,
Dist: Cachar, State: Assam
Application No. :
__________________________
(Signature of the candidate)
Email Id._________________________
ADMIT
Sri/ Smt/ Kumari : ___________________________________________________________
(Name of the candidate)
NOTE :
1. This should be properly filled and attached with the application form at the time of submission.
2. Candidate should bring the Admit Card at the time of Written Test.
3. Issue of Admit Card to Candidates opting for Silchar and Diphu Campus: From the
respective Department from 11.00 a.m. of July 03, 2015 onwards.
To be executed on non Judicial Stamp Paper of Rs. 20/- and to be submitted at the time of admission.
ANNEXURE I
AFFIDAVIT BY THE STUDENT
I, ____________________________________________, S/O/ D/O, Mr./ Mrs./ Ms. ________________
To be executed on non Judicial Stamp Paper of Rs. 20/- and to be submitted at the time of admission.
ANNEXURE II
AFFIDAVIT BY PARENT/GUARDIAN
_____________________________________
Signature of deponent
Name:
Address:___________________________
__________________________________
Telephone No./ Mobile No.
VERIFICATION
Verified that the contents of this affidavit are true to the best of my knowledge and no part of the affidavit
is false and nothing has been concealed or misstated therein.
Verified at ________________________ on this the _____________ of _____________, year___________
_____________________________________
Signature of deponent