Refund Form

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Application No P21
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 (For office use only)
guidelines before applying) University Provisional Reg. No.
To (if already issued)
The Project Head Student File No.

Division of Admissions Date of seat allocation
Lovely Professional University, Phagwara, Punjab. Date of seat DE allocation
Respected Sir/Madam,
I D.O.B. , aged (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
(Programme/ Residential/ Laundry/ Transport/ Parking Facility/ Mess Plan, Gym, Indoor Stadium specify).
The detail of the fee paid by me is as under:
For Office use only

Tick √ Mode of Fee
Receipt No. Refund Signature of
Particulars (which-ever Payment Deposited Date of
& Date Amount Payable the dealing
(DD/ Cash) Applying
Appli-cable) (In R) Deducted* official With
Refund (if any) UID
Programme Fee
Residential Charges
(Residence)
Charges for Mess &
its administration
Charges for Laundry
& its administration
Charges for Parking
Charges for Transport
Charges for Gym
Charges for Indoor
Stadium
Any other
Total
*For Deduction amount kindly refer Refund Policy.
Kindly pay refund amount in favour of(StudentName/ Parents Name)**
Preferred mode of payment for receiving refund amount (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 (only if refund is not for programme fee) Programme Fee/ Residential Charges (Residence)/ Charges for Mess &
its administration/ Charges for Transport & its administration/ Charges for Parking & its administration/ Charges for Laundry & its
administration/ Charges for Transport & its administration/ Charges for Gym/ Charges for Indoor Stadium (Specify)
**Note: Refund, if any, will be made through the account payee cheque only in the favour of concerned Student or Parent 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 73
.
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 √ For Office Use only

Sr.
Checklist (whichever Signature of dealing
No. Submitted Pending
Applicable) official With UID
1 Original fee receipt(s)
2 ID card (if already issued)
*Signature must be same as on application form for admissions

3 Mess Card (if already Issued)
4 Bus Pass (if already Issued)
5 Loan Letter (if already issued)
6 Any Other Document, Specify

Reasons for Refund (You can tick more than one option)
Distance Issue Financial Constraint Going Abroad Health Issue

Loan Constraint Not Eligible for Scholarship Not Eligible for Admission Personal Reason
if possible specify your
Dropping this Year Any Academic Related Issue In Campus Residential Issue reason in remarks)
Others/Remarks
Yours sincerely
Countersignature of the Parent or Guardian in case of minor applicant/student below 18

Signature of the Applicant* Signature of the Parent or Guardian*#
Date: Date:
(For Office use only)

Form received by Dealing Official Name UID Date Location
Whether the programme for which Refund is applied was Transferred from any other programme Yes No
Name of the 1st Programme in which admission was taken 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
I the undersigned, have received an amount (in Rs.) (in words)
on account of refund of [Programme Fee/ Residential Charges (Residence)/ Charges for Mess &
#
its administration/ Charges for Transport & its administration/ Charges for Parking & its administration/ Charges for Laundry & its
administration, 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: (Signature of Parents/Guardian*)
74 E&OE

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The Project Head Student File No.

For Ofﬁce use only

Tick √ For Ofﬁce Use only

1 Original fee receipt(s)

2 ID card (if already issued)

*Signature must be same as on application form for admissions

4 Bus Pass (if already Issued)

5 Loan Letter (if already issued)

6 Any Other Document, Specify

Distance Issue Financial Constraint Going Abroad Health Issue

Countersignature of the Parent or Guardian in case of minor applicant/student below 18

(For Ofﬁce use only)

Approval by Competent Authority

Place: Signature of Applicant)

Place: (Signature of Parents/Guardian*)

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