Govt.of Assam.

OFFICE OF THE PRINCIPAL

DISTRICT INSTITUTE OF EDUCATION AND TRAINING
JORHAT,TITABAR

Paste recent
Application Form for B.Ed. Course 2022-2024 colour
(Affiliated to Dibrugarh University) photograph

Use capital letters throughout.

1. Name of candidate:……………………………………………………………………………………………..

2. Name of father:…………………………………………………………………………………………………

3. Name of mother:……………………………………………………………………………………..................

4. Present/permanent Address…………………………………………………………………………………..

5. Phone number/Mobile number………………………………………………………………………………..

6. Police station………………………………………………………………………………………………….

7. Date of birth …………………………… 8.Sex:Male/Female...................................................................

9. Nationality: …………………………………….Religion…………..

10. Category:GEN/OBC/SC/ST/VHC/PHC(enclose certificate where necessary)…………………………

11. Result of Common EntranceTest,2022 Dibrugarh University (Enclose Score Car of DU CET 2022)

Admit card no Total marks Marks obtained Rank

12. Academic record from SSC(X standard onwards) (Enclose copies of certificates)

Examination Board/University SubjectsTaken Year of Total Marks % of

passing marks obtained marks/GPA

Class X
HSLC/CBSE/ICSE

Class XII

Bachelor’s
Degree(s)

Post Graduate(s)

Any other
13. DECLARATION BY THE APPLICANT:

I hereby declare that all the information furnished by me in this application and in the documents I have
submitted in support of my application is true, complete and correct. In case any information in this application is
found to be false or incorrect at anytime (during or after completion of the course), it shall entail automatic
cancellation of my admission, if granted, cancellation of the degree if awarded, besides rendering me liable to
such action as the University may deem fit.
In the event of any medical or other emergency, my parent/s or guardian may be contacted at the address given
below.

Place:

Date: Signature of the Applicant

14. DECLARATION BY FATHER/MOTHER/GUARDIAN:

My daughter/son/ward Mr./Ms............................................................................................................. is applying

for admission to the B.Ed. course under Dibrugarh University. In case of her/his admission to the University, I
shall be responsible for payment of all her/his fees and other charges including any emergency, medical or other
expenses incurred by the University/Institute. In case any information in this application is found to be false or
incorrect at any time (during or after completion of the course), it shall entail automatic cancellation of my
daughter’s/son’s/ward’s admission, if granted, cancellation of the degree if awarded, besides rendering her/him
liable to such action as the University/Institute may deem fit.I will also be responsible for her/his good conduct
and behaviour during the period of her/his stay in the Institute. Further, I may be contacted in the event of any
emergency as determined by the Institute or University and I hereby promise that I will make myself present
before the Institute or University authority at my own cost whenever the institute or university requires my
presence.

Father’s Occupation……………………………………....Annual income Rs………..…………………………...

Mother’s Occupation………………………………………Annual income Rs………………………….………...

………………………..………………………………………………………………………………………………

Place…………………………………
Signature of the Parent/Guardian
Date:
Name……………………………………….

Relationship with the applicant………………………………

Documents(Self attested) to be submitted along with application form:

1. DU CET 2022 score card

2. Admit card of ClassX
3. Marksheet from ClassX to Graduate and PostGraduate(All semester)
4. Caste certificate/EWS
5. Physically handicapped certificate.
6. Dibrugarh University registration card if passed out from Dibrugarh University.