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mijksDr Nk=@Nk=kvksa }kjk dk”kueuh okilh dh mDr izfdz;k laLFkku Lrj ij iw.kZ ugha dh
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INSTITUTE OF ENGINEERING & RURAL TECHNOLOGY, PRAYAGRAJ
ENGINEERING DEGREE DIVISION
APPLICATION FOR THE REFUND OF CAUTION MONEY
STUDENT FOLIO NO: ………….. STUDENT AKTU Roll NO: …………………………………
01. NAME OF STUDENT : ………………………………………………………………………………
02. FATHER’S NAME : ………………………………………………………………………………
03. DATE OF ADMISSION : ………………………………………………………………………………
04. BRANCH (B.TECH.) : ……………………………… MOBILE NO.: …………………………….
05. BANK ACCOUNT NO. : ……………….…………….……. IFSC NO.: ……………………………..
06. NAME OF BANK : ………………………………..… BRANCH: ……………………………..
07. (A) EDC CAUTION MONEY : 5,000 - 500 (One year membership of Alumni Society) = 4,500
(B) HOSTEL CAUTION MONEY : ……………………………………………………………………………..
08. REASON OF LEAVING THE INSTITUTE : ……………………………………………………………………………..
I declare that I wish to be a Member of IERT Engineering Degree Alumni Society. I am giving my consent to
deduct Rs. 500/- from my caution money (deposited in the institute) for the membership for one year of IERT
Engineering Degree Alumni Society. I also hereby request you that if any dues are pending against my name may be
deducted from my caution money in the balance may be refunded to me by cheque/DD/RTGS.
Name and Address: ………………………………………………….…………………………………………………………
SIGNATURE AND DATE
REPORT REGARDING DUES
NO DUES
01. College Fee (Account Section) : ……………………………………………………………………..
02. Hostel : ……………………………………………………………………..
03. Library : ……………………………………………………………………..
04. Games/Sports : ……………………………………………………………………..
05. Concerned Lab : ……………………………………………………………………..
06. Reference Library : ……………………………………………………………………..
APPROVED FOR REFUND OF RS. : ……………………………………………………………………..
DIRECTOR BILL PASSING ASSISTANT/DDO
(ACCOUNT SECTION)
PAID VIDE CHEQUE NO: ………………………………………… DATED: ………….…………. RS. …………………….…..
D.D.O DIRCTOR ENTERED IN FEES LEDGER FOLIO NO: ……............................
PAGE NO: ………………………….. YEAR: …………………….
SIGNATURE OF ACCOUNTANT
