ACADEMIC WINDOW (BLOCK 32-102; WINDOW 5), HELPLINE NO.
01824-444379
Application for REFUND
Student Name:____________________________ Regd. No:_____________________________
Father Name:______________________________Program Name:____________________________
Student Status:_________________________ Aggregate Attendance:_________CGPA_____
Student Contact No:_____________________Email ID:______________________________
Specify Term or semester for which you are applying for refund: _____________________________
(e.g. (Session-Term/Module (2324-1, 2324-2))
Refund Category[√]:: Residential De-allocation fee (Residence) Tuition Fee
Specify, in case any Other fee________________________________________________________
Program Complete or Program Discontinue
Is no-due cleared or not (Y/N)
Kindly confirm::The mode of payment[√]::Self Payment Loan Case Scholarship
(In case Loan / Scholarship case (YES)): (Supporting Documents to be attached like (NOC from bank /Govt)
Attach all the documents of refund as mentioned below: Please Tick √
Parent’s/Guardian written Consent letter/Scholar’s Consent Letter
Parent’s/Guardian ID Proof/Scholar’s ID Proof
Parent’s/Guardian Passbook / Scholar’s Passbook (IFSC No. and Account No. available).
Please mention A/C no. IFSC______________________________
__________________ _______________________
Signature of the student Parents/Guardian’s Signature
Date::_______________ Place::____________________
I declare that the above-mentioned information in this form is fully correct.
For Office use only
Attendance Details of Particular Term in which Student is Seeking Refund::
Term ID Total Delivered Attended Lecture %Age
Lecture
Within Policy ◯ Beyond Policy ◯
Amount to be refunded (Numeric)___________________________________________________________
Attached documents of refund have been verified & found Correct (YES/NO)_______________________
Remarks of Dealing official :: ______________________________________________________________
Dealing official Signature with Date & UID::_________________________________________________
Recommended by HOD with Date Recommended by HD with Date
