1. Name of the Candidate
in full (in Block Letters) :_______________________________________________________ 2. Fathers/ Mothers Name :_______________________________________________________ 3. Gender :__________________ 4. Date of Birth : ________________________________ 5. Registration No. of D.U. :___________________________ of _________________________ (Photocopy of the Registration Card is to be submitted)
6. (a) Degree applied for : ______________________ (b) Branch/Subject :__________________. 7. (a) Year of qualifying : ___________________ (b) Roll & No.: ________________________ (Photocopies of the Mark-sheet/Notification and Provisional Certificate are to be enclosed) 8. College/Department/Institute from where qualified: ___________________________________ _____________________________________________________________________________ 9. Particulars of Certificate Fee (Rs. 600/-) and Convocation Fee (Rs. 100/-) paid: [Fees to be paid at the Dibrugarh University Account No. 32968598069 of the State Bank of India, Dibrugarh University Branch through any Branch of the State Bank of India. The copies of the Bank Challan are available with the Application Form. The University shall not receive the fees of the Convocation in any other form.]
10. Address for communication:______________________________________________________ _____________________________________________________________________________ (With Mobile Number, if any): _________________________________________________ I certify that the above information are true to the best of my knowledge. I shall attend the Convocation.
(Signature of the Candidate)
Recommendation: (To be given by the Principal/H.O.D./Director etc.) I have verified the above information and found to be true. I recommend awarding the certificate, if otherwise found eligible.
(Please see overleaf)
CHECK LIST OF ENCLOSURES
1. Self Attested Copy of the Registration Card.
2. Self Attested Copy of the Mark-sheet(s) and Admit Cards.
3. Self Attested Copy of the Notification (in case of Ph.D. only). 4. Self Attested Copy of the Provisional Certificate (if received). 5. The University Copy of the Bank Challan of Fees Payment.