Application No.
APPLICATION FORM
FOR REFUND
INSTRUCTIONS
(Duly filled Application to be signed by the applicant; and to be countersigned by
Parent or Guardian in case of minor applicant below 18. Please go through guidelines
before applying)
To
D.O.B.
,aged
University Registration No.
(if already issued)
Student File No.
The Project Head, Allied Services
Division of Admissions
Lovely Professional University, Phagwara, Punjab.
Respected Sir/Madam,
I
(For office use only)
Date of seat allocation
Date of seat DE allocation
(years) S/o/D/o
R/o
applied/admitted for (as the case may be) the Programme
(Programme Code
) at Lovely Faculty of
seek to withdraw my application for admission/allotment (if already admitted or allotted) for the
(Tuition/Residential/Laundry/Transport/Parking Facility/Meal Plan specify).
The detail of the fee paid by me is as under:
Particulars
Tick
Mode of
(whichPayment
ever
(DD/
AppliCash)
cable)
Receipt
No. &
Date
For Office use only
Deduction Amount
Date of
Fee Deposited
Commence Processing
(In R )
-ment of
Charges
Session
( R 1000/-)
Proportionate
Monthly Fee
Deduction*
Refund
Payable (if
any)
Signature of
the dealing
official With
UID
Tuition Fee
Residential Fee
(Residence)
Residential Fee
(Meal)
Residential Fee
(Laundry)
Parking Fee
Any other
Total
*Proportionate Monthly Fee Deduction is equivalent to 1/5th of Tuition fee, 1/10th of Residential Fee (Residence), 1/10th of Transport fee, 1/10th of Residential Fee (Meal) if paid for academic session, 1/5th of
Residential Fee (Meal) if paid per semester, 1/10th of the Parking fee, and R500/- Residential Fee (Laundry) (which ever is applicable)
Kindly pay refund amount in favour of(StudentName/ Parents Name)*
I prefer mode of payment for receiving refund amount by (Tick and specify in writings)
Cheque, I would like to receive cheque by post or by hand from university campus (Specify in writing):
Adjustment in fee in ( only if refund is not for tuition fee) Tuition/Residential Fee (Residence)/Residential Fee (Meal)/Transport/
Parking fee/Residential Fee (Laundry) (Specify)
*Note: Refund, if any, will be made through the account payee cheque only in the favour of concerned Student or P arent as opted and written here by the applicant . Once the
application for refund has been submitted, then for any request to change the name of payee (student / parent in favour of whom cheque is to be prepared), or for request to reissue
the cheque because of postal delay or otherwise, additional processing fee of R 500/- will be charged.
E&OE 97
In this regard, you are requested to refund the fee after deductions as per guidelines. Kindly find enclosed herewith the documents issued
by the University,surrendered for the refund, as follow:
Tick
(whichever
Applicable)
Checklist
1.
Original fee receipt(s)
2.
ID card (if already issued)
3.
Mess Card (if already Issued)
4.
Bus Pass (if already Issued)
5.
Loan Letter (if already issued)
6.
Any Other Document, Specify_____________________
For Office Use only
Submitted
Signature of dealing
official With UID
Pending
*Signature must be same as on Admission Application Form
Sr. No
Reasons for Refund (You can tick more than one option)
Distance Issue
Financial Constraint
Going Abroad
Loan Constraint
Not Eligible for Scholarship
Not Eligible for Admission
Dropping this Year
Any Academic Related Issue
Health Issue
Personal Reason
(if possible specify your
reason in remarks)
In Campus Residential Issue
#Countersignature of the Parent or Guardian in case of minor applicant/student below 18
Others/Remarks
Yours sincerely
Signature of the Applicant*
Signature of the Parent or Guardian*#
Date:
Date:
(For Office use only)
Form received by Dealing Official Name
UID
Date
Whether the programme for which Refund is applied was Transferred from any other programme
Name of the 1st Programme in which admission was taken
Location
Yes
No
Programme Code
Date of Programme Transfer
Date:
Signature of Dealing officer With UID
Approval by Competent Authority
Date:
Signature of Competent Authority with UID
Approval by Accounts
Date:
Signature of Accountant With UID
Undertaking/Receipt
the undersigned, have received an amount (in Rs.)
on account of refund of
(in words)
[Tuition Fee/Residential Fee (Residence)/Residential Fee (Laundry)/Residential
Fee (Meal)/Transport/ Parking facility Fee, whichever applicable] through Cheque number
Dated
through Bank
; and hereby undertake that all my dues with the University are settled and no pending payment is due on either side.
Date:
Place:
(Signature of Applicant)
(To be countersigned by the Parent or Guardian in case of minor applicant below 18)
Date:
Place:
98 E&OE
(Signature of Parents/Guardian)
