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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)