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.

ASSAM UNIVERSITY
SILCHAR-788 011 CACHAR (ASSAM)

APPLICATION FORM FOR ADMISSION 2015-2016

Email Id.__________________________

No Column should be left blank. Incomplete appplication is liable to be rejected

COST OF APPLICATION CUM PROSPECTUS*

PAYMENT DETAILS: DD ( For downloaded forms only)

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.

RESULT IN THE QUALIFYING EXAMINATION

Name of the Qualifying Examination Honours Subject, if any Total Marks

% of Marks secured

GENERAL INFORMATION
Campus in which admission is sought

Silchar

Diphu

Name of the Course (Put tick () mark)

UG

Department in which admission is sought

: _____________________________________________

PG

Integrated

Diploma

PERSONAL INFORMATION
1.

Name ( in block letters)

: ______________________________________________

2.

Gender (Put tick () mark)

3.

Mothers Name

: ______________________________________________

4.

Fathers Name/ Husbands Name

: ______________________________________________

5.

Category* (Put tick () mark)

Male

SC

Female

ST

OBC

KASHMIRI MIGRANTS

Transgender

PWD

GEN

ANY OTHER

(Candidate belonging to category other than General Category

must attach certificate in support of his/ her claim )

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.

Marital Status (Put tick () mark)

11.

Permanent Address

Married

Single

Widowed

Divorced

_______________________________________

____________________________________ State ________________ Pin ________________

12. Address of Correspondence

_______________________________________

____________________________________ State ________________ Pin ________________

Phone_____________________________ Email. Id.__________________________________
13. Contact number of Father/ Mother/ Guardian :

_______________________________________

14.

_______________________________________

_______________________________________

Proposed Residence in Silchar

(Own House/Rented House/Hostel)

15.

Name and address of local guardian

_______________________________________
Telephone number : __________________________
16.

Are you employed? Put tick () mark

If yes, name and address of the employer

Yes

No

_______________________________________

(Attach a No Objection Certificate from the employer)

_______________________________________
17.

Have you applied for admission to more

than one department? Put tick () mark

Yes

No

If yes, please state the name of the departments

_______________________________________

18.

Are you already registered with

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?
:

_______________________________________

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.

If the result of the qualifying examination

of Assam University is yet to be announced,
please state the name of examination you appeared
with Roll No.
: _______________________________________

21.

Name of the Institution where last studied

22.

Were you ever disqualified by this or any

other university from appearing in any
examination? (Put tick () mark)

If yes, give details.

Is there any gap period in your study?

(Put tick () mark)
If yes, state the reason

23.

_______________________________________
Yes

No

_______________________________________

_______________________________________
Yes

No

_______________________________________

(Attach a gap certificate from the Head of the Institution you attended last or from a gazetted
officer).

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 and discipline rules as prescribed by the University and
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 and Interview / Aptitude assessment / Group discussion procedure and shall strictly abide by
all the instructions of the University authority in this regard.

(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 : _______________

Signature of the Candidate

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 : __________________

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)

Dean of the School

Place : ___________________

(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

For Courses in Diphu Campus

Send by post or deliver
To,
The Head,
Department of __________________________,
Assam University Diphu Campus,
P.O.- Diphu
Dist: Karbi Anglong, State: Assam

Application No. :

ASSAM UNIVERSITY, SILCHAR

(A Central University Established by an Act of Parliament)

Admission Test : 2015

To be filled by the candidate

__________________________
(Signature of the candidate)

Email Id._________________________

ADMIT
Sri/ Smt/ Kumari : ___________________________________________________________
(Name of the candidate)

to the examination for admission to the department of : _______________________________

(Name of the department)

to be held on Monday, the July 06, 2015 at 12.00 noon

(FOR OFFICE USE)
The Roll No. of the candidate is ___________________________________________________
_____________________________________________________________
Signature of H.O.D.

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. ________________

__________________________, 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 am aware 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 affirm that, if found guilty of ragging, I am liable 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 the affidavit
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 am aware 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 be constituted as ragging under clause 3 of the Regulations.
I hereby affirm that, 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 ward
under any penal law or any law for the time being in force.
I hereby declare that my ward has 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, 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 the affidavit
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