( Deemed University ) Nirjuli () ::: – 791 109

APPLICATION FORM FOR DEGREE/ DIPLOMA / BASE CERTIFICATE OF NEHU

1. Name of the Candidate (IN CAPITAL LETTERS) …………………………………………………...... ………………...... …………………………………………………………………………………………………………...….…………………………… 2. Name of the Degree applied for ………………………………………………………………..…………………………………….. 3. Name of the Department…………………………………………………..………………………………………….………….…… 4. Registration No………………..……………Roll No………………………………….Year of Passing………...…………..…… 5. CGPA………………………………. 6. Address for Correspondence ………………………………………………………………………………………………….……… ……………………………………………………………………………………………………………………………………….…... ………………………………………………………………………………………………………………………………………….... E-mail …………………………………………………………………….… Phone No. ……………….…………..……………….. 7. Mode of payment of prescribed fee. If cash, Cash Receipt No. ………………………….…… Date :...………………….…… If Demand Draft, DD No. ………………………… Date…………….……… Issuing Branch ……......

Counter signed by: Head of the Department Signature of the Candidate Name:…………………………………………………………. Full Name:…………………………………...... …… Date:…………………………………………………………... Date:……………………………………………………

NOTE : The prescribed fee of the certificate is Rs.200/- (Rupees two hundred) only. Payment is to be made to the Cash Section, Finance Branch, NERIST and receipt thereon is to be produced to the Examination Cell/Acad. Section at the time of receiving the original certificate or Rs. 250/- (Rupees two hundred and fifty) only Crossed Bank Draft on State Bank of , Nirjuli (Code No.9535) payable in favour of DIRECTOR, NERIST. N.B.: 1. The candidate should submit a photo copy of Degree Provisional Certificate or No dues Certificate. 2. The Certificate will be issued within a week from the date of submission of Application form. 3. Certificate will be issued to the candidates in person or may be sent on the permanent address. In case of emergency requirement at working address, the candidate may receive the certificate if the employer gives a declaration that the applicant is working in his/her firm with permanent address as given below: ------

The permanent address given above and signature of the applicant will be verified from records available with the institute. After that certificate will be sent to the working address.

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