GOVERNMENT AUTONOMOUS COLLEGE, ROURKELA

APPLICATION FORM FOR MPHIL 2ND / PG 4th / UG 6th SEMESTER ONLINE EXAMINATION 2021

(To be filled by the candidate by hand in BLOCK LETTERS, Put wherever necessary)

nd th th
Select Exam & Sem () : MPhil 2 PG 4 UG 6 Regular Back

1. Examination Roll No ___________________ 2. University Regd. No ___________________

3. Name (in Capital) __________________________________________________________
4. Sex (MALE / FEMALE) ______________ 5. Caste (OBC/SC/ST/GEN) _________________
6. Examination appearing for (Put mark where applicable) :

PG 4th P-401 P-402 P-403 P-404 P-405 P-406 UG 6th C-13 C-14 DSE-3 DSE-4
Sem Sem

7. Address for Communication:

___________________________________________________________________________
___________________________________________________________________________
Pin Code ______________ Mobile No (mandatory) _________________________________
8. Payment Details (Attach copy of Receipt Detail) :
Ref. No ________________________ Date _______________ Amount _______________
Amount in words ____________________________________________________________
9. Status of other semester (Put mark for CLEAR or BACK, mention Passing Year if CLEAR) :
CLEAR BACK PASSING YEAR (if Clear) CLEAR BACK PASSING YEAR (if Clear)
Sem-1 Sem-4
Sem-2 Sem-5
Sem-3

10. Undertaking by the candidate (should be written in own handwriting) :

Date : Signature of the candidate

 UNDERTAKING FORMAT
(To be written by the candidate inside the specified space)

I, (Name of the Candidate) do hereby undertake that I am wilfully appearing the Online
Examination. I shall abide by all the rules and regulations of the examination framed by the
college authority. I shall send all the needful documents & the Answer Scripts to the
specified departmental Email-Id only within the given time frame.

The college may reject my candidature if any of my acts deviates the guidelines.