NOTE : Printout to be taken not in separate sheet but in both sides of a single legal-size sheet.

DOWNLOADED
(For 2nd Semester onwards)

Last Sem. Exam. Roll ..................................... Paste

Passport
No. ..................................................... of AUS
Size
AU Regn. No.......................... of................... Photograph
(To be filled by the Department) here
(do not staple)
Roll..................... No.........................................
(To be filled by the University)

ASSAM UNIVERSITY :: SILCHAR

APPLICATION FORM FOR UNDER GRADUATE (INTEGRATED COURSE) / POST
GRADUATE EXAMINATIONS
[Put tick (P )mark in applicable box]

UG (Integrated) PG Diploma Examination, 20 ____

Semesters : 1 2 3 4 5 6 7 8 9 10

SCHOOL _______________________________ DEPARTMENT ___________________

PARTICULARS TO BE FILLED UP BY THE CANDIDATE

1. Name in full (BLOCK LETTERS) .......................................................................................................................

2. Registration No. .................................................. of ...................................

3. Fathers / Guardians Name.................................................................................................................................

4. Mothers Name................................................................................................................................................

5. Date of Birth : ___/___/_____ 5. Nationality :............................... 6. Religion .............................................

6. Sex : Male Female 8. Category : General SC ST OBC PWD (Please put tick ( P)mark)

7. Home Address : .........................................................................................................................................

..................................................................................................................................................................

8. Date of Admission in First Semester ........................................................

Course(s) to be appeared .........................................................................

Course No. Paper Name Paper Code Paper Name
ARREAR PAPERS
GENERAL PAPERS

14. Whether debarred from any examinations conducted by the University, If Yes, state :
(a) Examination which was cancelled ..................................................................................
(b) Examination from which debarred ...................................................................................
(c) Year / Years in which punished .....................................................................................

Date : Signature of the Candidate in full

 2

To
The Dean, School of ............................................................................................................
Assam University, Silchar-788 011

Sir,
I request you for permission to present myself at the ensuing ............................................. Semester UG
(Integrated)/PG Examination to be held in the month of ................................ 20........ The fee receipt is enclosed
herewith.
I testify that, to the best of my knowledge abd belief all the statements made by me are true and correct.
If any of the statements made in the application is incorrect in the opinion of the authority of the University or I have
in any way contravened the provision of the University rules and regulation relating to the Examination my application
shall be liable to be cancelled by the authority of the University at any time.

Yours obediently

Place :........................... Signature in full :......................................................

Date :............................ Correspondence Address :........................................

...............................................................................

Phone ................................ (M) ....................... (L)

.............................................Pin

LAST EXAMINATION APPEARED

Examination Roll No. Month Year
............... Semester
............... Semester
............... Semester
............... Semester
............... Semester
............... Semester
............... Semester
............... Semester
............... Semester
............... Semester

CERTIFICATE
Certified that the above named candidate has fulfilled all the eligible criteria to appear for the above examination
and that he/she.
(i) has cleared the sessional evaluation in the subjects for which he/she is a candidate.
(ii) has satisfied the stipulation regarding attendance.
(iii) has paid the prescribed examination fee & other dues.
(iv) nothing is known against his/her conduct and character which debars his/her from appearing in the
examination.

Place :................................

Date :................................... Signature of the Head of the Deptt.

(Seal)

Forwarded the application form of UG/PG examination............................................................. in respect of

............................................................... Department along with the copies of requisite documents for necessary
permission to sit at the ensuing examination.

Place ................................ Signature of the Dean of the School.......................................

Date.................................. (Seal)

To
The Controller of Examinations
Assam University, Silchar