Application No.
TEZPUR UNIVERSITY
NAPAAM::TEZPUR – 784028 : ASSAM
APPLICATION FORM
(For Original certificate of the Ph.D. Degree)

1. Name in full (block letters in English and Hindi):..……….……………………………………………………………
……………………………………………………………………..
2. Home address in full: ..……….……………………………………………………………
..……….……………………………………………………………
..……….……………………………………………………………
3. Present address for communication: ..……….……………………………………………………………
..……….……………………………………………………………
..……….……………………………………………………………
4. Title of the Thesis: ..……….……………………………………………………………
..……….……………………………………………………………
..……….……………………………………………………………
5. Year in which the candidate was declared: ..……….……………………………………………………………
to have qualified for the Ph.D. degree
(With BoM resolution No.& Date)
6. Name(s) of the supervisor(s) with address: ..……….……………………………………………………………
7. Department: ..……….……………………………………………………………
8. School: ..……….……………………………………………………………
9. Tezpur University Registration No. with year: ..……….……………………………………………………………
10. Roll No: ……………………………………………………………………...
11. Convocation fee of Rs. 500/deposited
to : Bank draft / T.U. cash receipt no. …………………………….
the University vide Date …………….
12. Mode of receiving the Certificate :
(Please tick the appropriate box)
Full signature of the candidate
Attested copies of Provisional certificate, Registration certificate and Convocation fee paid receipt should be enclosed
For office use
Verified receipt no. …………………….Dated ………………
Dealing Official
Recommended / Not recommended Countersigned
Head, Department of…………… Controller of Examinations
Rs. 500/(Rupees five hundred) only should be enclosed as Bank Draft in favour of the Registrar, Tezpur
University payable at Tezpur or may be paid in cash at the T.U. cash counter. The students admitted to Ph. D. programme since Autumn Semester, 2005 need not pay the convocation fees.
at the convocation by post in person Through a person
authorized by the awardee