For other than ST/SC
Form No. _ _ _ _ _ _ _ _ _ _ _ _ _ _
TEZPUR UNIVERSITY
For office use only
NAPAAM, TEZPUR - 784028, ASSAM
(Ph.D. Programme)
Selected provisionally under
Gen/PWD/OBC(NCL)/KM**
category
Paste one recent passport
size photograph
Head of the Department
Admitted /
provisionally admited
APPLICATION FORM
For admission to Spring Semester 2013
Controller of Examinations
(Read the prospectus carefully before filling in the Form)
To be submitted to the Head of the Department on or before the specified date
1. Category of candidature
sought (Please tick 9)
Full time
Part time
Sponsored
Project Fellow (Full Time)
2. Department applied for
3. Area of Interest
(i)
(ii)
(iii)
(Provide one page write up on your area of interest)
4. Name in full (Block Letters)
5. a) i) Fathers/Husbands Name
a) i) ......................................................................................................
ii) Occupation
ii) ......................................................................................................
b) i) Mothers Name
b) i) ......................................................................................................
ii) Occupation
ii) ......................................................................................................
..........................................................................................................................
6. Correspondence Address
..........................................................................................................................
..........................................................................................................................
Pin : ................................................ E-mail : ...................................................
Phone No (with STD code): ..............................................................................
..........................................................................................................................
7. Permanent Address
(if different from the above)
..........................................................................................................................
..........................................................................................................................
Pin : ................................................ E-mail : ...................................................
Phone No (with STD code): ..............................................................................
8. (a) Date (DD/MM/YY) & place of birth:
(b) Age as on 31.12.2012:
9. Nationality
10. State of Domicile
11. Religion:
12. Category (Please tick 9)
Gen
SC
ST
*Person with Disability
OBC (NCL)
PWD*
KM**
** Kashmiri Migrant
13. Are you employed? (Please tick 9) : Unemployed / Employed temporarily / Employed permanently
(If employed, Employers Sponsorship / No Objection Certificate in prescribed format should be attached)
14. Gender :
(M / F) :
15. Marital Status (M / U)
For ST/SC Only
Form No. _ _ _ _ _ _ _ _ _ _ _ _ _ _
TEZPUR UNIVERSITY
For office use only
NAPAAM, TEZPUR - 784028, ASSAM
(Ph.D. Programme)
Selected provisionally under
ST/SC category
Paste one recent passport
size photograph
Head of the Department
Admitted /
provisionally admited
APPLICATION FORM
For admission to Spring Semester 2013
Controller of Examinations
(Read the prospectus carefully before filling in the Form)
To be submitted to the Head of the Department on or before the specified date
1. Category of candidature
sought (Please tick 9)
Full time
Part time
Sponsored
Project Fellow (Full Time)
2. Department applied for
3. Area of Interest
(i)
(ii)
(iii)
(Provide one page write up on your area of interest)
4. Name in full (Block Letters)
5. a) i) Fathers/Husbands Name
a) i) ......................................................................................................
ii) Occupation
ii) ......................................................................................................
b) i) Mothers Name
b) i) ......................................................................................................
ii) Occupation
ii) ......................................................................................................
..........................................................................................................................
6. Correspondence Address
..........................................................................................................................
..........................................................................................................................
Pin : ................................................ E-mail : ...................................................
Phone No (with STD code): ..............................................................................
..........................................................................................................................
7. Permanent Address
(if different from the above)
..........................................................................................................................
..........................................................................................................................
Pin : ................................................ E-mail : ...................................................
Phone No (with STD code): ..............................................................................
8. (a) Date (DD/MM/YY) & place of birth:
(b) Age as on 31.12.2012:
9. Nationality
10. State of Domicile
11. Religion:
12. Category (Please tick 9)
Gen
SC
ST
*Person with Disability
OBC (NCL)
PWD*
KM**
** Kashmiri Migrant
13. Are you employed? (Please tick 9) : Unemployed / Employed temporarily / Employed permanently
(If employed, Employers Sponsorship / No Objection Certificate in prescribed format should be attached)
14. Gender :
(M / F) :
15. Marital Status (M / U)
16. Hostel Accommodation required ? (Y / N) :
(Not applicable for part time applicants)
17. Educational Qualifications starting from 10th standard or equivalent onwards :
Exam.
Passed
Board / University / Year of Class / Subjects taken (including Honours % of Marks
Institute
passing Division
/ Major, if any)
/ Grade
Remarks
HSLC
(10th std)
10+2 std.
Degree*
PG
Others
* Please mention the name of the Degree e.g. BSc / BA / BV Sc / BE etc.: if appeared enter the marks secured in last examination.
18. Have you qualified UGC-CSIR NET - JRF / SRF / NET (LS) / SET / GATE ? If yes, give score : .....................
19. Academic Distinction / Medals / Prizes, if any :
(May attach extra sheet, if required)
20. Were you
a) Debarred from any examination(s)? [Y / N]
b) Punished for misconduct ? [Y / N]
If yes, please furnish details
21. Specialized academic training (if any)
: ............
:
22. Any other point you wish to add that will support your candidature for the Programme including your
publication (may attach extra sheet, if required)
23. Declaration to be signed by the candidate
I declare that I shall abide by the Statutes, Ordinances, Rules, and Orders etc. of the University that will
be in force from time to time. I will submit myself to the disciplinary jurisdiction of the Vice-Chancellor and the
authorities of the University who may be vested with such power under the Act, Statutes, Ordinances and the
Rules that have been framed there under by the University.
I also declare that the information given above is true and complete to the best of my knowledge and
belief, and if any of it is found to be incorrect, my admission shall liable to be cancelled and I shall be liable to
such disciplinary action as may be decided by the University.
Place : .
..
Full signature of the candidate
Date: ..
Enclosures check list (tick whichever is applicable):
1.
2.
3.
4.
5.
Valid SC / ST / NCL (OBC) certificate / Person With Disability (PWD) certificate (if applicable). Recent (issued not
earlier than 6 months) Non-Creamy Layer certificate( NCL) is a must in case of candidate claiming seat under OBC
category,
Sponsorship / No Objection Certificate (if applicable),
Bank Draft of prescribed amount (if the form is downloaded),
Attested photocopies of the certificates supporting educational and other qualifications.
Acknowledgement cum Admit card
_________________________________________________________________________________________
N. B. No acknowledgement will be sent for non-eligible candidates.
Eligibility fulfillment is the responsibility of the candidate. Please Note the eligibility criteria carefully.
Form No.
For Ph.D. Programme
(Format for Sponsorship / No objection Certificate)
(The letter should be typed on the Official Letter-Head of the Sponsoring Organization / Employer /
Principal Investigator & signed by the Head of Institution / Principal Investigator)
To
The Controller of Examinations,
Tezpur University
Sub:
Sponsorship / No objection Certification of Mr./ Ms. ____________________________________
For Ph.D. Programme at Tezpur University.
Dear Sir / Madam,
Mr. / Ms. _____________________________________________________ has been working in
this organization / Project as ____________________________ since __________________________.
This organization has no objection to his / her being admitted to the Ph.D. Programme at Tezpur
University from the session starting from _________________ as a part time / full time student.
Mr. / Ms. ____________________________________________________ is hereby sponsored
for carrying out the Ph.D. programme. (only for sponsored candidate).
The employee will be relieved from his / her duties in the organization to join in the Ph.D.
Programme (not applicable to project fellow).
Date:
Signature________________________________
Place:
Name___________________________________
Designation______________________________
Seal of the Sponsoring authority / employer
For Office Use Only
1.
Verified by : Signature : _______________________________________ Date: _________________________
Name:__________________________________________________ Designation: _____________________
2.
Recommended / Not Recommended:
Signature: _____________________________________________________
Name : _______________________________________________________
Chairman, Selection Committee
Head, Department of ____________________________________________
Date: ______________________________
TEZPUR UNIVERSITY
Ph.D. Entrance Examination for Spring Semester - 2013
Acknowledgement cum Admit Card
Form No...............................
To be filled by candidate
Offering Department
Name and Address of the Candidate
Paste one
recent
passport size
colour
photograph
...............................................................
...............................................................
...............................................................
...............................................................
Candidates Signature
To be filled by Office
Name and Address of
Examination Centre
Date and Time of Entrance
Examination
Entrance Examination Roll
Number
Signature of issuing Officer
TEZPUR UNIVERSITY
Ph.D. Entrance Examination for Spring Semester - 2013
Acknowledgement cum Admit Card
Form No...............................
To be filled by candidate
Offering Department
Name and Address of the Candidate
...............................................................
...............................................................
...............................................................
Paste one
recent
passport size
colour
photograph
...............................................................
Candidates Signature
To be filled by Office
Name and Address of
Examination Centre
Date and Time of Entrance
Examination
Entrance Examination Roll
Number
Signature of issuing Officer
Applied for Ph.D. Programme
Senders name & address :
.......................................................................
.......................................................................
.......................................................................
.......................................................................
.......................................................................
To :
The Head,
Dept. of .....................................................
Tezpur University
Napaam, Tezpur
Pin : 784 028
Dist : Sonitpur, Assam
