DIBRUGARH

UNIVERSITY
Degree

For Official Use

Roll No.

APPLICATION FOR ADMISSION TO THE CONVOCATION

[To be submitted to the Academic Branch, D.U.]
1. Name of the Candidate
in full (in Block Letters) :_______________________________________________________
2. Fathers Name

:_______________________________________________________

3. Male/Female :__________________ 4. Date of Birth : ________________________________

5. Registration No. of D.U. :___________________________ of _________________________
(Photocopy of the Registration Card is to be submitted)
6. (a) Degree applied for : ______________________ (b) Branch/Subject :__________________.
7. (a) Year of qualifying : ___________________ (b) Roll & No.: ________________________
(Photocopy of the Mark-sheet/Notification/Provisional Certificate is to be enclosed)
8. College/Department/Institute from which qualified: ___________________________________
_____________________________________________________________________________
9. Particulars of Certificate Fee (Rs. 600/-) and Convocation Fee (Rs. 100/-) paid: [Fee may be paid
either in the Dibrugarh University Cash Counter or by a Demand Draft in the name of the
Registrar, Dibrugarh University payable at State Bank of India, Dibrugarh University Branch
(Code No. 2051). [No Postal Order or Money Order will be accepted.]
(a) D.U. Cash Counter Receipt No.: _____________________ of Book No.: _______________
Date: ___________________________ (Duplicate copy of the Receipt must be enclosed)
(b) Demand Draft: Demand Draft No.: _________________________ Date: _______________
10. Address for communication:______________________________________________________
_____________________________________________________________________________
(With Telephone Number, if any): _________________________________________________
I certify that the above information are true. I shall attend the Convocation.

Date: _________________

__________________________
(Signature of the Candidate)
Recommendation: (To be given by the Principal/H.O.D./Director etc.)
I have verified the above information and found to be true. I recommend to award the
certificate, if otherwise found eligible.

Date: _________________

__________________________
(Signature)
Official Seal
(Please see overleaf)

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CHECK LIST OF ENCLOSURES

1. Copy of the Registration Card
2. Copy of the Mark-sheet(s) and Admit Cards
3. Copy of the Notification (in case of Ph.D. only)
4. Copy of the Provisional Certificate (if received)
5. Demand Draft/University Cash Receipt

FEE PARTICULARS

1. If applied for receiving the certificate in the convocation

Rs. 600.00

(Convocation Fee Extra)

2. If applied after one year from the date of passing

Rs. 750.00

3. If applied after two years from the date of passing

Rs. 900.00

4. If applied after three years from the date of passing

Rs. 1,050.00

5. If applied after four years from the date of passing

Rs. 1,200.00

6. If applied after five years from the date of passing

Rs. 1,350.00

7. If applied after six years from the date of passing

Rs. 1,500.00

8. If applied after seven years from the date of passing

Rs. 1,650.00

9. If applied after eight years from the date of passing

Rs. 1,800.00

10. If applied after nine years from the date of passing

Rs. 1,950.00

11. If applied after ten years or more from the date of passing

Rs. 2,100.00

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