TEZPUR UNIVERSITY
Application for Railway Concession Certificate

1. (a) Name with home address : …………………………………………………………
…………………………………………………………
…………………………………………………………
…………………………………………………………
(b) Roll No. : …………………………………………………………
(c) Department : …………………………………………………………
(d) Programme : …………………………………………………………
(e) Sex (M/F) : …………………………………………………………
(f) Age : …………………………………………………………

2. Purpose of journey : visit to institution/home town /examination centre
/educational tour / training.
3.
Railway Station From To
Onward Journey
Return Journey

4. Date of journey :
a. Onward:
b. Return:
5. Booking Station :
a. Onward journey:
b. Return journey:
6. Journey is proposed during Spring semester recess/ Autumn semester recess/ other period (Please specify)

Signature of the candidate
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7. Recommendation of HoD : Recommended / Not recommended

Signature of HoD with seal
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FOR OFFICE USE

Certificate prepared by Verified by Signed by

Dealing Assistant Assistant Registrar (Acad) /S.O. (Acad) Controller of Examinations