Application No.
TEZPUR UNIVERSITY
NAPAAM:: TEZPUR-784 028::ASSAM
APPLICATION FORM
(For Original Certificate of UG/PG Degree/Diploma)
(to be filled in by the applicant)
1. Name in full (block letters in English and Hindi): ………………….……………………………………………………………………
………………….……………………………………………………………………
2. Home Address: ………………….……………………………………………………………………
………………….……………………………………………………………………
3. Correspondence address: ………………….……………………………………………………………………
…………………………………………… Phone No. …………………………….
4. Programme of study completed: ………………….……………………………………………………………………
5. Enrolment No.: ………………….……………………………………………………………………
6. Registration No. with year, if any: ………………….……………………………………………………………………
7. Year of passing ………………….……………………………………………………………………
8. Details of previous semester examinations
Sem
Sem type (Autumn/Spring)
Year of passing
Credit completed CGPA
Semester Semester
(Autumn/Spring)
Year of passing
Credit completed
CGPA
1 st
2 nd
3 rd
4 th
5 th
6 th
7 th
8 th
9 th
10 th
9. Total credit completed:
10. Whether awarded any E and F Grades(s) in any previous examination: Yes/ No
If yes i. In which course(s): Course Code …………………. Course Title ………………………………………… …………………..
ii. In which semester these grades are converted to the higher grades: …………………………………………………………
iii. Grade awarded after conversion …………………………………………………………………………………………………
10. Whether put on academic probation: Yes/No
If yes i. In which course(s): Course Code ………………….. Course Title ………………………………………………………………..
ii. When did you clear the academic probation: ……………………………………………………………………………………..
iii. Grade awarded after clearance of academic probation: ………………………………………………………………………….
11. Mode of receiving certificate
(please tick √)
I, ________________________________________________________hereby declare that the above particulars are true to the best of my
knowledge and belief. If found otherwise, I shall be liable to any action.
Date: Full signature of the candidate
NB: Please enclose attested copies of grade cards and provisional certificate.
At convocation By post In person
RECOMMENDATION OF THE HEAD OF THE DEPARTMENT/ CENTRE
Certified that Mr./Ms. …………………………………………………………………………. with Enrolment No. ………………………
was a student of the Dept. / Centre and passed ……….. th Semester End Examination with CGPA ………….. and completed the credits requirements (Credit required …………………….. for degree/ diploma/ certificate
Certificate may be issued to Mr. / Ms. ………………………………………………………………………………………………………...
Head , Dept. / Centre …………………………………………………………………
For office use only
Convocation No: Convocation Date: Certificate No:
Prepared by Verified by Certificate signed
Dealing Official Controller of Examinations/DR (Academic) Registrar Vice Chancellor