LALA RURAL COLLEGE

LALA HAILAKANDI ASSAM - 788163

(ESTD.-1964)
Affiliated to Assam University - A Central University
Accredited by NAAC

APPLICATION FORM
Previous Class Roll No.: for Admission to FOR OFFICE USE ONLY
274 FYUG 2nd Year Semester III
Roll No.:
SAMARTH / Univ. Reg. No. : Arts
666162310150 Date of Admission:
Session : 2024-25

Application Serial No.: 512400501 AUS Appl Sr No.:

UID : U2303512479790 ABC ID : 762968901717

1. Name of Applicant : ANITA PASHI

2a. Mobile No : 8011780602
2b. Alternate Mobile No :
3. AADHAR Number : 362340583058
4a. Email ID : ganeshpashi79@gmail.com
4b. Alternate Email ID :
5a. Date of Birth : 01/06/2003 5b. Age as on 1st July : 21
6. Gender : Female
7. Religion : Hinduism 9. Community : HINDU
8. Caste / Category : OBC
9. Do You Want to Avail FEE WAIVER SCHEME of Assam Govt.: NO
10. Are you citizen of India : Yes
11. Nationality : INDIAN
12. Domicile : Assam
13. ID Proof : Other Valid Govt. ID
14. ID Proof No : 362340583058
15. Other Category / Quota : a. Extra Curricular Activity : Not Applicable
b. Person with Benchmark (PWBD) Category : : Not Applicable
c. Are you from Tea Garden Community? : Yes
d. Are you Kashmiri Migrant? : Not Applicable
e. Prime Minister Special Scholarship for J&K Students : Not Applicable
f. Are you Ex-Serviceman ? : No
g. Are you descendant of freedom fighter? : No
h. Are you Single Girl Child ? : No
16. Address Details :
PERMANENT ADDRESS PRESENT ADDRESS

Address Line 1 VILL LALAMUKH T E VILL LALAMUKH T E

Address Line 2
Post Office LALAMUKH LALAMUKH
Police Station LALA LALA
District HAILAKANDI HAILAKANDI
State ASSAM ASSAM
PIN 788163 788163
Cluster Name LALA LALA
Block Name LALA LALA
LAC Name LALA

17. Family Information :

a. Mother's Name : PURNIMA PASHI
b. Father's Name : PURAN PASHI
c. Local Guardian's Name :
UID : U2303512479790 ABC ID : 762968901717

Qualification Occupation Office Address Phone No.

Father Non Graduate Self Employed N/A N/A
Mother Non Graduate Un Employed N/A N/A

d. Combined Family Income : 98000 e. Emergency Contact No :

18. University Registration Details :
a. Have you enrolled in University / Autonomous Colleges before: Yes
b. If Yes Enrollment No: 666162310150
c. Name of University / Autonomous College:
d. Program registered with the University / Autonomous College:
e. In Case of any break of studies, the period and reasons thereof are to be stated: Period:
Reason:
f. Registration No. (If any): 20230019765 of: 2023
g. In Case of Transfer : Certificate No. Date :
Cause of Transfer

Permission Letter No. Date :

19. Academic Details

Name of Division/
Examination Name of Year of Roll Full Marks
Board/Council/ Subjects Grade
Institution Passing No. Marks Obtained
University Point/ %

Semester II AU LALA RURAL ECODSC151T, ECODSC152T, 2024 022423 450 0

COLLEGE, LALA PHPDSM151T, PLSIDC151T,
ENGAEC151T, ECOSEC152P 010100180

Marks Details of Last Examination :

ECODSC101 100.00 22.00
ECODSC102 100.00 17.00
BNGDSM101 100.00 25.00
PLSIDC101 100.00 25.00
ECOSEC101 100.00 40.00
BNGAEC101 50.00 14.00
NSSVAC101 100.00 32.00

20. Subjects Preferred :

Pref DSC 201 DSM 201 DSM 202 IDC 201 SEC 201 AEC201
1 ECONOMICS BENGALI PHILOSOPHY POLITICAL ECONOMICS MIL BENGALI
SCIENCE

21. Other Details : a. Do you have any illness which require continuous or emeregency medical attention: No
b. Do you belong to Moran Community of Assam: No
c. Do you belong to fringe village of Assam: No
d. Area of Residence Rural
e. Are you Son / Daughter of Present Employee of college No

f. Are you Son / Daughter of Ex - Employee of college No

g. Do you have migration certificate No
h. Do you have transfer certificate from school / college No
i. Candidate havinf NCC 'B' 'C' certificate No
j. Have You attended any special camp under NSS No
UID : U2303512479790 ABC ID : 762968901717
22. Bank Details : Bank Name : PNB, LALACHERRA
Account Number : 1310010455541 IFSC Code : PUNB0131020
23. Blood Group :
24. Whether willing to stay in the Hostel: NO
25. Have you applied in some other colleges?: NO Kg
26. Mother Tongue : BENGALI Height: 165 Cm Weight: 45
27. DECLARATION BY THE APPLICANT :
I do hereby declare that
i. the above particulars submitted by me are correct to the best of my knowledge and belief
ii. I shall abide by the rules and regulations of the college failing which the college authority may take any step which it deems fit and proper.
iii. I shall do nothing in or outside the college that may impair the discipline, good name and honour of the college.
iv. I shall attend the classes regularly and secure attendance of not less than 75% in each subject as stipulated by Assam Higher Secondary Education
Council / Assam University. I am fully aware that attendance of less than 75% in any of the subjects will debar me from appearing in the Council /
University Examinations.
v. I shall appear in all internal assessments and tests conducted by the college and secure the minimum prescribed marks in each subject.
vi. I will conform to the uniform and dress code in its entirety prescribed by the college.

vii. I will not use Mobile Phone inside the college campus.
viii. I will neither indulge in nor provoke any ragging inside or outside the campus. I am fully aware that involving in ragging is an offence and
punishable as per law.

If any of the above statements or information is found to be incorrect or if my conduct/ attendance/ result is not satisfactory, my
admission is liable to be cancelled and I shall have no claim to continue as student of this college.

(Signature in full of Father/Mother/Guardian) (Signature in full of the Candidate)

14/08/24
Date: ..................................
14/08/24
Date: ..................................

FOR OFFICE USE ONLY

SEC CORE GEN ELECTIVEADDL GEN ELECT

Subjects
Recommended

Admission Fee : Rs. 4060.00

Convenor, Admission Committe

Dealing Assistant (ADMISSION)

Cashier's Report Principal's Report

Received ₹ ...................................................... Admit Provisionally

Receipt No. ....................Date .........................

Principal
Signature of Cashier ........................................

LIST OF ENCLOSURES
1. Passport size Photo (2 Copies)
2. Application Form of Assam University
3. Admit Card of HSLC or equivalent examination.
4. Marksheet of HSLC/X, HS/XII Examination.
5. Pass / Character Certificate from the Head of the Institution last attended for admission into HS-1 / TDC-1
6. Admit Card and Marksheets of last TDC examinations (For TDC 3rd & 5th Sem.)
7. Caste Certificate (if any)
8. Sports / NCC / Scout Certificate (if any)
9. Valid Income Certificate and photograph of tree planted if you want to avail Fee Waiver Scheme of Assam Govt.
UID : U2303512479790 ABC ID : 762968901717

Submission of online forms with subject combination does not guarantee admission. Admission will be finalised
by Admission Committee alongwith subject combination on the date of merit list publication (for 1st Sem only)

UNDERTAKING FOR ATTENDENCE

I ANITA PASHI do, hereby, give the
undertaking that I shall attend 75% of the classes failing which I will not
be allowed to fill up the forms of TDC/HS Final Examination conducted
Assam University, Silchar or Assam Higher Secondary Council, as the
case may be.

(Signature in full of Father/Mother/Guardian) (Signature in full of the Candidate)

Date: 14/08/24 Date: 14/08/24

CAUTION REGARDING RAGGING ACTIVITY

Any kind of involvement in ragging activity or giving indulgence to

such activity is a punishable offence as per the "UGC Regulations
on curving the menace of ragging in higher education institutions,
2009" notified on 4th July 2009 in the Gazette of India in persuance
to the judgement of the Hon'ble Supreme Court of India dated
08.05.2009 consequent upon Civil Appeal No. 887/2009.

Admission Fee : Rs. 4060.00

Application Serial No.: 512400501
Name of Applicant.: ANITA PASHI

Class and Sem: FYUG 2nd Year Semester III

Stream: Arts