Form - A

Application no: 18113406

Course Name BE/BTECH
Candidate's Name : MEHFUZA     AHMED
Date of Birth : 02/04/1999
Father Name : MD GIAS UDDIN
Mother Name : AKLIMA AHMED
Centre of Examination : Guwahati
Nationality : Indian
Gender : Female
Category : OBC/MOBC (Other)
Address : BATELI TEA ESTATE
PIN-784507
MAZBAT
City : MAZBAT
Dist : UDALGURI
State : ASSAM
Pin Code : 784507
Phone No. : 361-9101452665
Mobile No. : 7002968600
E-Mail. : GIASUDDIN.BATELI@GMAIL.COM
Permanent Resident of Assam : Yes
Declaration :
I declare that the entries in the Online Application Form have been filled up and the entries made are correct as per my
documents and to the best of my knowledge and belief. I agree that if any statement is proved to be false then the
Authority shall have the right to take legal action against me for submitting false information or statement. I further
declare that there is no allegation of misconduct against me and I have never been covicted for any offence involving
moral turpitude.

Date : ______________

Place : _____________