ASSAM UNIVERSITY

SILCHAR-788 011 CACHAR (ASSAM)

APPLICATION FORM FOR ADMISSION 2014-2015
Email Id.______________________
No Column should be left unfilled. Incomplete appplication is liable to be rejected
Candidate opting for Examination Centre other than Silchar and Diphu should legibly
write his/her email id., so that Admit Card can be sent to his/her email id. In the case of
such a candidate not providing his/her email id. must attach a self addressed envelop
affixing postal stamp of Rs. 40.00 for the dispatch of admit Card by post.
DOWNLOADED FORM
Affix latest Passport size
photograph duly
attested from top by the
Principal of the School/
College last attended or
by a gazetted officer.
GENERAL INFORMATION
Campus in which admission is sought : _____________________________________________
Name of the Course : _____________________________________________
Department in which admission is sought : _____________________________________________
Centre you opt for Admission Test : _____________________________________________
PERSONAL INFORMATION
1. Name ( in block letters) : ______________________________________________
2. Mothers Name : ______________________________________________
3. Fathers Name/ Husbands Name : ______________________________________________
4. Category* Put tick mark : SC ST OBC PWD GEN
KASHMIRI MIRANTS ANY OTHER
(Candidate belonging to category other than General Category
must attach certificate in support of his/ her claim )
FILLED IN APPLICATION FORM MUST REACH THE UNIVERSITY BY MARCH 31, 2014
* SC :: Scheduled Caste, ST :: Scheduled Tribe, OBC :: Other Backward Class, PWD :: Person With
Disabilities, GEN :: General
COST OF APPLICATION CUM PROSPECTUS
SC/ST Others
Prospectus 500.00 500.00
Application fee Nil 100.00
Total 500.00 600.00
PAYMENT DETAILS: CASH/ DD (Put mark)
Name of Bank :
Amount :
D.D. No. :
Date :
RESULT IN THE QUALIFYING EXAMINATION
Name of the Qualifying Examination Honours Subject, if any Total Marks % of Marks secured
(ii)
5. Nationality : ________________________________
6. Religion : ________________________________
7. Marital Status Put tick mark : Married Single
8. Permanent Address : ________________________________
________________________________
Phone_____________________________ Email. Id._______________________________
9. Proposed Residence in Silchar : ______________________________________
(Own House/Rented House/Hostel)
10. Name and address of local guardian with : ______________________________________
telephone No.
______________________________________
______________________________________
______________________________________
11. Are you employed? Put tick mark : Yes No
If yes, name and address of the employer : ________________________________
(Attach a no Objection Certificate from the employer)
________________________________
12. Have you applied for admission to more : Yes No
than one department? Put tick mark
If yes, please state the name of the departments: ______________________________________
13. Are you already registered with : Yes No
Assam University? Put tick mark
If yes, state the Registration No. with year : ______________________________________
(Attach a copy of Registration Certificate)
If not registared, how much time you will require to
apply for registration to Assam University
along with the Migration/ Transfer certificate
in original? : ________________________________
(Maximum time allowed for submitting application for University Registration is 60 days from
the date of admission).
FILLED IN APPLICATION FORM MUST REACH THE UNIVERSITY BY MARCH 31, 2014
(iii)
14. Educational Qualifications : Please enclose attested copies of all documents in support of educational qualification,
date of birth etc.
High School
Higher Secondary
BA/BSc/BCom
(Pass/General)
BA/BSc/BCom
(Major/Hons)
Any other exam.
................................
Examination
School /
College
Board / Council
/University
Subjects Year Division
% of
Marks
Distinction
15. If the result of the qualifying examination
of AssamUniversity is yet to be announced,
please state the name of examination you appeared
with Roll No. : _________________________________________
16. Name of the Institution where last studied : _________________________________________
17. Were you ever disqualified by this or any : Yes No
other university fromappearing in any
examination? Put tick mark __________________________________
If yes, give details. : __________________________________
20. Is there any gap period in your study? : Yes No
Put tick mark
If yes, state the reason : _________________________________________
(Attach a gap certificate from the Head of the Institution you attended last or from a gazetted
officer).
FILLED IN APPLICATION FORM MUST REACH THE UNIVERSITY BY MARCH 31, 2014
For Courses in Silchar Campus:
Application may be dropped in the Drop Box
placed in the Academic Section of the
University or may be sent by post addressed
to the Section Officer (Academic), Assam
University, Silchar - 7880011.
For Courses in Diphu Campus:
Application may be dropped in the Drop Box
placed in the office of the Assam University
Diphu Campus or may be sent by post to
Admission i/c, Assam University, Diphu
Campus, Diphu, Karbi Anglong.
21. Information for Statistical Purpose
a) Category(SC/ST/ OBC/PWD/General) ______________
b) Rural / Urban ________________________________
c) Fathers/ Mothers Annual Income ________________
d) Occupation__________________________________
(iv)
Declaration by the Candidate
I hereby solemnly affirm that I shall strictly abide by the rules and regulations of the University, as amended and enforced from
time to time and also of the students conduct & discipline rules as prescribed by the University & enforced from time to time.
I am neither involved in any criminal case nor is any criminal case pending against me in any court of law. I have not been
debarred /rusticated by the institution last attended/presently attending. If discovered even after confirmation of my provisional
admission that I have made a false or incorrect statement or concealed any fact or fraudulent means or such means have been
used on my behalf for securing admission, I shall be liable to disciplinary action and cancellation of admission without prejudice
to such action as the University may take against me. I fully agree to follow the Admission test or Interview / Aptitude
assessment / Group discussion procedure and shall strictly abide by all the instructions of the University authority in this
regard.
I, ____________________________, hereby solemnly declare on oath that the entries made by me in the above columns 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.
Permanent Address : Village/Town :_____________________________________ P.S.____________________________
P.O. :_________________________ District_______________________ State_______________ Pin_______________
Telephone No._____________________________________________________(Email Id._______________________)
Place : _______________
Date : _______________ Signature of the Candidate
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.
________________________________
Full signature of Guardian
Place : _________________
Date : __________________
FOR USE IN THE DEPARTMENT
Certified that the application is in order / not in order. The candidate is recommended/not recommended for admission.
(Signature)
Chairperson, Departmental Admission Committee
ADMITTED/REGRETTED
(Signature) (Signature)
Dean of the School Head of the Department
Place : ___________________
Date : ___________________
Application No. :
ASSAM UNIVERSITY, SILCHAR
(A Central University Established by an Act of Parliament)
Admission Test : 2014 ____________________________
To be filled by the candidate (Signature of the candidate)
Email. Id._________________________
(Candidate opting for Examination Centre other than Silchar and
Diphu must legibly write his / her email id. for having the Admit Card
sent to that id. In the case of such a candidate not providing email. id.,
a candidate must attach a self addressed envelope affixing postal
stamp of Rs. 40.00 for the dispatch of Admit Card by post).
ADMIT
Sri/ Smti/ Kumari : _______________________________________________________________
(Name of the candidate)
to the examination for admission to the department of : ___________________________________
(Name of the department)
to be held on Sunday, the July 06, 2014 at ______________________________________ Centre
at 12.00 noon/ 01.00 p.m.
(Name of the Centre)
(FOR OFFICE USE)
The Roll No. of the candidate is _______________________________________________________
_____________________________________________________________
Signature of H.O.D./ Chairperson, Admission Committee with (Seal)
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. Admit Card of candidates opting for Examination Centre other than Silchar and Diphu will be sent
to the email id., if provided.
4. In the case of the candidate opting for Examination Centre other than Silchar and Diphu but not
providing email. id., must attach a self addressed envelop affixing postal stamp of Rs. 40.00 for thedispatch
of Admit Card by post.
5. Issue of Admit Card to Candidates opting for Silchar and Diphu Centre: From the respective
Department from 11.00 a.m. of July 05, 2014 to 11.00 a.m. of July 06, 2014.

ASSAM UNIVERSITY, SILCHAR

(A Central University)
FORMAT FOR IDENTITY CARD
(To be filled in by Capital letters only)
Name :___________________________________________
Department : ______________________________________
Course : ___________________________ Session : 2014-15
Date of Birth : _______________________
Blood Group : _______________________
Fathers Name : ____________________________________________
Mothers Name : ____________________________________________
Permanent Address _________________________________________
_________________________________________________________
Identification Mark : __________________________________________
Telephone No : _____________________________________________
Signature of HOD Signature of card holder
N.B.: Signature to be given within the margin.
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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. _____________

__________________________, having been admitted to ___________________________________,
have received a copy of the UGC Regulations on Curbing the Menace of Ragging in Higher Educational
Institutions, 2009, (hereinafter called the Regulations) carefully read and fully understood the provisions
contained in the said Regulations.

I have , in particular, perused clause 3 of the Regulations and amaware as to what constitutes ragging.

I have also, in particular, perused clause 7 and clause 9.1 of the Regulations and am fully aware of the
penal and administrative action that is liable to be taken against me in case I am found guilty of or abetting
ragging, actively or passively, or being part of a conspiracy to promote ragging.

I hereby solemnly aver and undertake that:

a) I will not indulge in any behaviour or act that may be constituted as ragging under clause 3 of the
Regulations.
b) I will not participate in or abet or propagate through any act of commission or omission that may be
constituted as ragging under clause 3 of the Regulations.

I hereby affirmthat, if found guilty of ragging, I amliable for punishment according to clause 9.1 of the
Regulations, without prejudice to any other criminal action that may be taken against me under any penal law or
any law for the time being in force.

I hereby declare that I have not been expelled or debarred from admission in any institution in the
country on account of being found guilty of abetting or being part of a conspiracy to promote ragging; and
further affirm that, in case the declaration is found to be untrue, I am aware that my admission is liable to be
cancelled.
Declared this _________________ day of ______________month of ____________ year __________
_______________________
Signature of deponent
Name:
VERIFICATION
Verified that the contents of this affidavit are true to the best of my knowledge and no part of theaffidavit is false
and nothing has been concealed or misstated therein.
Verified at __________________ on this the _____________ of _____________, year___________
_______________________
Signature of deponent
Solemnly affirmed and signed in my presence on this the ______________ of ___________,___________
after reading the contents of this affidavit.
OATH COMMISSIONER
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

I, Mr./Mrs./Ms. ________________________________________, (full name of parent/guardian)

father/mother/guardian of,____________________________________________, who has been admitted
to ___________________________________, have received a copy of the UGC Regulations on Curbing
the Menace of Ragging in Higher Educational Institutions, 2009, (hereinafter called the Regulations) and I
have carefully read and fully understood the provisions contained in the said Regulations.

I have , in particular, perused clause 3 of the Regulations and amaware as to what constitutes ragging.

I have also, in particular, perused clause 7 and clause 9.1 of the Regulations and am fully aware of the
penal and administrative action that is liable to be taken against my ward in case he/she is found guilty of or
abetting ragging, actively or passively, or being part of a conspiracy to promote ragging.

I hereby solemnly aver and undertake that:

a) My ward will not indulge in any behaviour or act that may be constituted as ragging under clause 3 of
the Regulations.
b) My ward will not participate in or abet or propagate through any act of commission or omission that
may beconstituted as ragging under clause 3 of the Regulations.

I hereby affirmthat, if found guilty of ragging, my ward is liable for punishment according to clause 9.1
of the Regulations, without prejudice to any other criminal action that may be taken against my wardunder any
penal law or any law for the time being in force.

I hereby declare that my ward has not been expelled or debarred fromadmission in any institution in the
country on account of being found guilty of, abetting or being part of a conspiracy to promote ragging; and
further affirm that, in case the declaration is found to be untrue, the admission of my ward is liable to be
cancelled.
Declared this _________________ day of ______________month of ____________ year __________
_______________________
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 theaffidavit is false
and nothing has been concealed or misstated therein.
Verified at __________________ on this the _____________ of _____________, year___________
_______________________
Signature of deponent
Solemnly affirmed and signed in my presence on this the ______________ of ___________,___________
after reading the contents of this affidavit.
OATH COMMISSIONER
ASSAM UNIVERSITY LIBRARY
ASSAM UNIVERSITY, SILCHAR
Phone No. 03842-270849/ 270887/ 270832
LIBRARY MEMBERSHIP FORM
(Use Capital Letter Only)
1. NAME
Last Name First Name Middle Name
Fathers Name: _________________________________________________________________________________________________
Mothers Name: ________________________________________________________________________________________________
Guardians Name: ______________________________________________________________________________________________
2. Date of Birth : Date Month Year
3. Members Category (U.G./ P. G./ M. Phil./ Ph. D. Student) : _____________________________________________________________
4. Members Academic Information :
Department of _____________________________ School of _____________________________________________________
Semester _______________________ Year ______________________ Session _______________________________________
Class Roll No. ____________________________
5. Present Address ______________________________________________________________________________________________
Vill/ Town: ________________________________________ P.O. ________________________________________________________
Dist. __________________________________ State ____________________________ Pin ___________________________________
Phone No. STD _____________________ No. ____________________ E-mail _____________________________________________
6. Permanent Address ___________________________________________________________________________________________
Vill/ Town: ________________________________________ P.O. ________________________________________________________
Dist. __________________________________ State ____________________________ Pin ___________________________________
Phone No. STD _____________________ No. ____________________ E-mail _____________________________________________
7. Details of Fee Receipt: No. _______________________________________ Date: __________________________________________
(Enclosed Xerox copy of Fee Receipt)
Forwarded by Head of the Deptt.
(Signature of Head of the Dept. with seal) (Signature of Student)
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
(For Office Use only in Library)
1. Effective Date of Membership and Validity from_________________________________ to _________________________________
2. Membership Code Members ID (Membership No.) __________________________________________________________________
3. Fee Receipt No. ________________________________________________ Date: _________________________________________
Signature of In-Charge with date
(N.B. all entry are mandatory) Librarian
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