No: CET1700536

APPLICATION FORM FOR APPEARING IN THE COMMON ENTRANCE TEST

FOR ADMISSION TO THE 2-YEAR B.Ed. PROGRAMME OF
DIBRUGARH UNIVERSITY
SESSION: 2017-2019

1. Name of the Candidate in full (Block Letters):

First Name Middle Name Surname

Ms. PALLABI GOGOI

2. Address for Correspondence:

Care Of: Prabin Gogoi. udaipur Gaon. daily bazaar. new settlement area.
P.O. Duliajan. dist: Dibrugarh. State: Assam PIN 786602
Mobile/ Tel.No.(with STD
Code) 9435039472 e-mail pallabigogoi199@gmail.com

3. Father's/Guardian's Name and Address:

Name: Mr. Prabin Gogoi

Address: Udaipur Gaon. daily bazaar. new settlement area.
P.O. Duliajan. dist: Dibrugarh. State: Assam PIN: 786602
Mobile/Tel No (with STD
Code) 9435039472 Email

4. Date of Birth:
(According to the HSLC Day Month Year
Certificate) 2 1 0 9 1 9 9 6

5. Nationality: Indian

6. Sex: (Please tick ) Male Female

7. Community: (Please tick ) SC ST(P) ST(H) OBC/MOBC GENERAL

8. Whether differently abled? (Please tick ) Yes No
(If yes, please submit Medical Certificate issued by the Joint Director of Health Services of the District
concerned at the time of admission)

9. Highest Educational Qualification:

Degree Board/Council/College Roll No. Year of Divn./Class Parcentage of

Examination Passing Marks
Passed in All Subject
B.A. Dibrugarh University 12510101 Appearing

** Important Note:
The University shall not verify the eligibility of a candidate at the time of receiving their Application
Forms and Issuing Admit Card to them for the B.Ed CET 2017. The candidates not fullling the
minimum eligibility criteria shall not be debarred from appearing the B.Ed. CET, 2017. However, their
candidature shall not be considered at the time of admission to the B.Ed. Programes conducted by
Dibrugarh University and its aliated colleges. Hence, the intending candidates are requested to
ensure themselves regarding fulllment of the minimum eligibility for admission into the B.Ed.
Programme.

10. Examination centre in which the candidate would like to appear:

Centre Code Name of the Test Centre

1701 Dibrugarh University, Dibrugarh

Declaration
I declare that the information given above are true and complete to the best of my knowledge and
belief and if any of these is found to be incorrect, my admission shall be cancelled and I shall be liable to
such other disciplinary action as may be decided upon by the University.

Date: 19/05/2017
Place: Duliajan

Signature of the candidate