DEBRAJ ROY COLLEGE

WEB VERSION
DEBRAJ ROY COLLEGE
GOLAGHAT - 785621, ASSAM
Session : 2015-2016
Application for Admission into (use  mark)
I
II
SEMESTER
III
IV
V
VI
Full Name of the Applicant
(In Block Letters)
2. Sex (use  mark) :
Male
Female
3. Date of birth (according to HSLC Admit Card):
ARTS
STREAM
SCIENCE
SHIFT
MORNING
DAY
1.
4.
5.
6.
7.
8.
Nationality
Religion
Day
Month
Year
(Enclose attested photocopy of Certificate)
Father’s Name: Mr. ………………………………………………………………………………………………………………………………
Mother’s Name: Ms ……………………………………………………………………………………………………………………………
Permanent Address
……………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………...
Address for Communication : Place ………………………... P.O…………………………..
Dist. ……………………………...
PIN ………………………..
Contact Ph. No. …………………….
E-mail…………………………...
Legal/Local Guardian’s Name : …………………………………………………………………………………………………………
Address: …………………………………………………………………………………………………………
Occupation:………………… …. Relation to the Applicant: ……………………. Ph.No. ………………
9.
Indicate to which of the following category do you belongs to ( use  mark) (Enclose attested photocopy of Certificate) :
SC
ST(P)
ST(H)
OBC
MOBC
TGL
PH
Other ________________________
10. Proficiency in other activities like Sports / Music / Drama / NCC etc.
Level of Participation (use  mark) :
Na-
tional
State
(Enclose attested photocopy of Certificate)
11. Particulars of Last Examination Passed :
(a) Name of Examination : _________________________________________________________________ Year____________
(b) Name of the Institution : ________________________________________________________________________________
(c) Name of the Board/University/Council : _____________________________________________________________________
(d) Roll_________________ No.______________ Registration No. ____________________ Division / Class : ___________
(e) Marks obtained in the examination Subject wise (Enclose attested photocopy of Marksheet) :
Subjects
% Marks
Full Marks
Marks secured
12. Subjects Sought :
As mentioned in the
prospectus
Combination of
Subjects
(Preferencewise)
1st preference
Major Subject (Office
use only)
2nd preference
3rd preference
13. Hostel Accommodation (use  mark) : Wanted
Not Wanted
(Separate form to be submitted)
The above information is correct, I shall abide by the rules and discipline of the College. I understand that I am liable to be punished for violation of
rules and discipline.
____________________________
____________________________
Signature of the Father/Guardian in full
Signature of the candidate in full
Date _____________
N.B.:
Date _____________
Original Certificates will have to be produced at the time of admission.
Only National and State level participation / position will be considered for Sl. No. 10
............................................................................................................................. .......................................................................................................................
FOR OFFICE USE ONLY
Admitted with the above combination of subjects
Hostel allotment : ________________
Date : ____________
Stream : _____________________
Shift : _________________
Class
Roll No. : _________________
: _____________________
Signature of Chairperson of Admission Committee
Signature of the Principal
Important Note: This is a WEB VERSION admission form downloaded from www.debrajroycollege.org. Duly filled up form
should be submitted in the office (not in Drop Box) along with the prospectus fee of Rs. 130/- only.