DIBRUGARH UNIVERSITY

DIBRUGARH – 786 004

APPLICATION FORM FOR MIGRATION CERTIFICATE

To
The Registrar
Dibrugarh University
Dibrugarh – 786 004

Sir,
I have the honour to state that I am a registered student of your University and I
would like to migrate from your University.I request you to issue me a Migration
Certificate. Necessary particulars are given below:

1. Name in full (in Block letters) :___________________________________

2. *Dibrugarh University Registration No :______________________Year_________
3. College/Department, where studied last :___________________________________
4. Name of the Examination, appeared last :___________________________________
5. Result of the last examination :___________________________________
6. Roll Number with year of the aforesaid Examination:__________________________
7. **Whether appeared as Private/Regular student:______________________________
8. Whether expelled from appearing at any examination(s):________________________
9. Place of migration :___________________________________
10.Reason for migration :___________________________________
11.***Particulars of payment of Migration fee:
Receipt/ Date Amount
D.D. No.

12. Complete address to which the Migration

Certificate should be sent :
___________________________________
____________________________________
13. Enclosures sent herewith:
(a)
(b)
(c) ______________________________
Signature of the candidate
Date______________
 Certificate by the Head of the Institution last attended by the candidate

I certify that the particulars given above, by the candidate, __________________

_________________is true as per the records. He may be issued the Migration
Certificate.

Date:__________ _____________________
Seal of the Institution Signature
Name: ________________________
Designation: ___________________

(2)

Note:

* (1) Original Registration Receipt must be surrendered along with this

application form.
In case of loss of Original Receipt, Duplicate Registration should
be obtained and submitted.

** (2) In case Private student the application must be countersigned by a Govt.

Gazetted Officer.

*** (3) Migration Fee: Prescribed Migration Fee [at present Rs. 300/- (Rupees
three hundred)]. The fee may either be deposited in the
University Cash Counter or through a Demand Draft of
Rs. 300/- in the State Bank of India, Dibrugarh
University Branch (Code 2051) in favour of the
Registrar, Dibrugarh University. Demand Draft in
other Bank, Branch or in favour of anybody else will not
be accepted.