DOWNLOADED FORM
ASSAM UNIVERSITY : SILCHAR
APPLICATION FOR OBTAINING CERTIFICATE
PROVISIONAL / ORIGINAL
(See overleaf for Rules)
1. Name of the Student (in Block letters as written in Regn. Card) __________________________________________________________

2. A.U. Registration No. with year __________________________________________________________
3. Father’s/Husband’s Name in full __________________________________________________________
4. Full Postal Address for Communication with Phone No. __________________________________________________________
__________________________________________________________
5. Details of Exam Passed for which applying of certificate ________________________________________________
Examination Passed
Name of Board / University
Year of Passing
Examination Roll No.
Division / Class / Simple Pass
Name of School / College
6.Fees paid :-
Amount in Rs.
Payment receipt No. & Date
Crossed Bank Draft No. & Date
Application No.
Date of Receipt
Dealing Asstt.
DECLARATION BY THE APPLICANT
I declare that the above particulars are true to the best of my knowledge and belief. In case any statement made by me is found to be incorrect my application shall be liable to be cancelled.
Date : ………………….. Full Signature of the applicant
RECOMMENDATION OF THE PRINCIPAL/HOD OF PG DEPARTMENT
This is to certify that Shri/Smt. ___________________________________________ Regn. No. ________________ of ___________ a student of _____________________________ passed the _________________ Examination 20 ____ held in 20 ____ vide Examination Roll ___________No. ____________________ under Assam University and was placed in ____________________ Class/Division/ Pass. The certificate as applied for may be issued.
Memo No. ______________ Signature of the Principal/HOD of PG Deptt.
Date ___________________ Name in full (in Block Letters)________________________________
Office Seal & Date ___________________
OFFICE NOTES & ORDERS
Examination record verified and found correct/ incorrect. Fees as shown have
been paid
Checked
Certificate may be/ may not be
prepared
Recommended for
Signature
Certificate placed opp for signature
Dealing Asstt.
Section Officer
Assistant Registrar (E)
Deputy Registrar (E)
RULES
1. The application must be completed in every respect and should be submitted through the Principal of the College concerned/Head of the Deptt., Assam University (as the case may be) along with the prescribed fees. The applicant shall be required to enclose with the application (a) Photostat copy of the Registration Certificate/Migration Certificate duly attested (b) Photostat copy of final mark-sheet for which original certificate is applied for duly attested.
Incomplete application will be summarily rejected without further communication. Incorrectness or inaccuracy of information submitted may lead to rejection of the application and in such case fees deposited shall not be refunded.
2. The current rate of fees are as under:
Name of Certificate
Fees for Provisional Certificate
Fee for Original Certificate
Master Degree
P.G. Diploma
Bachelor’s Degree
100.00
750.00
This is however subject to change.
3. All prescribed fees should be sent by Bank Draft payable to the "Assam University" at the UCO Bank / State Bank of India or be deposited with A.U. Cash Counter.
4. Generally the Certificate will be handed over to the candidate concerned on proper identification. If certificate is required by post self addressed stamped envelope of size 11 x 5 to be submitted along with the application.
5. The Original Certificate shall be issued only after holding of Convocation of that particular year.
Specimen Signatures of the applicant to be attested by the Principal of the College / Head of the Institution / Head of the Department from where he / she passed the Exam.
_________________________
Name of the applicant in full
Address :
Specimen Signatures
1.________________________
2.________________________
3.________________________
Signature attested
Principal / Head of the
Institution / Head of the Department
with office seal
Allowed
C.O.E. / Deputy Registrar (E)
2012-06-07