NAPAAM, TEZPUR-784028, ASSAM / Paste one recent passport size photograph
Selected provisionally under Gen/SC/ST/PWD category
Head of the Department
Admitted/
Provisionally admitted
Controller of Examinations
APPLICATION FORM- A
(Read the prospectus carefully before filling in the Form)
To be submitted to the Head of the Department (for MBA programmes),
Controller of Examinations (for Ph.D. programme) on or before the specified date
1. a) Programme applied forb) Department / a) ………………………………………………….
b) ………………………………………………….
2. Name in full (Block Letters)
3. a) i) Father’s/Husband’s Name
ii)Occupation
b) i) Mother’s Name
ii)Occupation / a) i) ………………………………………………….
ii) ………………………………………………….
b) i) ………………………………………………….
ii) ………………………………………………….
4. Guardian’s Name & Address / ……………………………………………………….
………………………………………………………..
………………………………………………………..
Pin: …………………… E-mail….……………..……
Phone No (with STD code) ………..……………….
5. Correspondence Address / ……………………………………………………….
………………………………………………………..
………………………………………………………..
Pin: ……………………………………………..……
Phone No (with STD code) ………..………………
6. Permanent Address / ……………………………………………………….
………………………………………………………..
………………………………………………………..
Pin: ……………………………………………..……
Phone No (with STD code) ………..………………
DD / MM / YY / Place
7. Date & place of birth 8. 8.
Gen / SC / ST / OBC / MOBPWD / KM / Minority Community
9. Category (Please tick ) (a) (b)
(c) Religion
10. Are you employed? (Please tick ) 11. Gender (Please tick ) 12. Marital Status (Please tick )
Male / FemaleSingle / Married
Yes / No
(If yes, Employer’s No Objection Certificate in prescribed form to be attached)
13. Hostel Accommodation (Please tick ) 14. MAT OMR No.
(Not applicable for Part-time students) (Only for MBA Full time programme)
15. Name and address of the Institute last attended:
…………………………………………………………………………………………………
16. Qualifying Examination
Submitted / Will be submitted / Self Employed / Not Applicable17. No Objection Certificate from Employer whether submitted (Please tick the appropriate box)
18. Educational Qualifications starting from 10th standard or equivalent onwards:
Exam. passed / Board/University/Institute / Year of passing / Class/Division / Subjects taken(including Honours/Major, if any) / % of aggregate Marks/Grade / Rank obtained (if any)
HSLC (10th Std)
10+2
Degree*
* Please mention the name of the Degree e.g. B.Sc./BA/BV Sc./BE etc. ; If appeared enter the marks secured in last examination.
19. Marks obtained in Mathematics in 10+2 examinations (if any)
20. Academic Distinction/Medals/Prizes, if any
21. Have you qualified in GATE? If yes, please provide
- Extra Curricular Achievements: NCC/NSS/Sports/Cultural Activities etc.
……………………………………………………………………………………………………………………….
23. Are you attending any other academic programme (s): (Please tick )
Yes / NoIf yes, i) Name of the programme……………………………………………………...….
ii) Name of the Institution ………………………………………………………….
iii) Expected date of completion……………………………………………………
24. Were you a) Debarred from any examination (s) ? : [Yes/No] (Please tick )
b) Punished for misconduct? : [Yes/No] (Please tick )
If yes, please furnish details : ……………………………………………………………………….
25. If employed, details of employment:
Organization / Duration / Position / Regular/Temporary/Ad hoc etc. / Nature of duties
26. If employed, whether leave will be granted/already granted:
27. Specialized training (if any):
- Any other point you wish to add that will support your candidature for the programme
(may attach extra sheet, if required)
29. 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:…………………………………
Date:…………………………………. Full signature of the Candidate
- Declaration of the Guardian ( For MBA full-time Programme)
I undertake the responsibility of all dues of my son/daughter/ward regularly and for his/her due compliance with all rules and regulations that are in force from time to time in the University.
Place:…………………………………
Date:…………………………………. Full signature of the Guardian
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Enclosures check list (tick whichever is applicable):
1.Caste Certificate/PRC/PWD certificate (if applicable),
2.No Objection Certificate (if applicable)
3.Bank Draft (if the form is downloaded),
4.Acknowledgement Card (Self Addressed) with postage stamp affixed,
5.Self attested photocopy of certificates supporting educational and other qualifications.
- Copy of MAT OMR Application Form (For MBA Full Time programme)
- Form B, Form III, Form IV, Form V (For Ph. D programme)
(if applicable)
FORM – B
(To be filled-in by candidates for Ph.D. programme only in addition to Form-A)
- Name of the applicant (in block letter) : ……………………………………………………..
- Teaching / Research experience : ……………………………………………………………
(Mention level of teaching – UG/PG/College/Institute/Courses taught/Area of research)
- Tick () the category of candidate sought :
Full time Part time Project fellow Sponsored
- Seminar / workshop / Conference attended after post graduation :
(Use separate sheets if necessary)
- Scholarship / fellowship awarded for research (if any give details):
- Qualified in NET/JRF or similar with year (Enclose certificate) :
- List of Publication (if any) :
(Enclosed separate sheet if necessary)
For Office Use Only
- Verified by : Signature : ______Date: ______
- Recommended / Not Recommended:
Name : ______
Chairman, Selection Committee
Head, Department of ______
Date:______
FORM – C
For MBA Part-time Programme
Format for “No Objection Certificate”
(The letter should be typed on the Official Letter Head of the Employing Organization)
Ref No ………………….…
Date …………….…..
To:
The Controller of Examinations,
Tezpur University
Napaam – 784 028 (Assam)
Sub:No Objection Certificate
Dear Sir,
The organization has no objection if Mr./Ms…………………………..…………………
Who has been working in this organization as………………………………….., is admitted to the MBA (Part-time) programme in Tezpur University for the academic session ……………………….. as a part-time student.
The organization will allow him/her to attend classes during 5.00 pm to 8.30 pm on weekdays.
DateSignature of the Issuing Authority
Place Designation……………………………
FORM-III
For Ph.D. Programme
(Format for Sponsorship Certificate )
(The letter should be typed on the Official Letter-Head of the Sponsoring Organization)
To
The Controller of Examinations,
Tezpur University
Sub: Sponsorship of Mr./Ms______
for Ph.D. programme at Tezpur University.
Dear Sir/ Madam,
Mr./Ms ______who has been working in this organization as ______is hereby sponsored for carrying out the Ph.D. programme at Tezpur University from the session ______as a full time student.
The employee will be relieved from his/her duties in the organization to join in the Ph.D. programme.
Date: Signature: ______
Place: Name: ______
Designation: ______
Seal of Sponsoring authority.
FORM-IV
For Ph.D. Programme
Format for “No-Objection Certificate” from Employer
(The letter should be typed on the Official Letter-Head of the Employing Organization)
Ref No: ______
Date: ______
To
The Controller of Examinations,
Tezpur University
Napaam,
Tezpur
Sub: No objection certificate
Dear Sir/ Madam
It is hereby certified that Mr./ Ms. ______has been working in this organization as ______.
This organization has no objection to his/her being admitted to the Ph.D. programme at Tezpur University from the session starting on ______as a part time student.
Signature:______
Date:
Name: ______
Place:
Designation : ______
Seal of sponsoring authority.
FORM-V
For Ph.D. programme
Format for No-Objection Certificate from Principal Investigator
(In case of Project Fellow in the official letter head of Principal Investigator)
Ref No: ______
Date: ______
To
The Controller of Examination
Tezpur University
Napaam,
Tezpur
Sub: No objection certificate
Dear Sir,
Certified that Mr./Ms. ______is working as a ______in the project ______in the department/Centre ______funded by ______since______. I have no objection in allowing him / her to join the Ph.D. degree programme at Tezpur University under the category of project fellow.
Further, he / she will be allowed to do his course work / research work of the Ph.D. programme without hampering the project work.
Signature:
Date:
Name:
Place:
Designation
Seal of Principal Investigator
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