PUNJAB TECHNICAL UNIVERSITY, JALANDHAR

RE-REGISTRATION FORM (Session S11-M12) - DEP

(To be filled in by the student in Block Letters)

PERSONAL INFORMATION
LC CODE ROLL NO. FATHER NAME COURSE PERM. ADDRESS SCHEME LC NAME NAME LC CITY MOBILE
RES. PHONE

SEMESTER

FOR CANDIDATES WHO HAVE TAKEN PROVISIONAL ADMISSION

Qualifying Examination Passed: Yes / No Degree/Diploma Board/University Passed in % of Marks

APPLICABLE SEMESTER & EXAM FEE

Semester & Exam fee = .+=..Late fee..Total Amount.. Narration DD-1 DD-2 DD-3 Total Amount DD no. DD Date DD Bank

SPECIALIZATION SUBJECTS & PAPER ID (if applicable*)

Subject Name Paper ID (As per date sheet manual)

Have you ever been disqualified? Yes / No Give details, (if yes) ___________________________________________________
I have understood the methodology of filling the OMR answer sheets & have done the mock practice. Any wrong/incomplete information given by me in this form or the answer sheet is my responsibility & I shall be accountable for all delays occurring out of such ambiguities. Certified that the Candidate has completed all eligibility requirements and has paid all requisite fee of the University as a student of Distance Education Mode of Punjab Technical University, JALANDHAR.

I hereby declare that all the information given above is true & to the best of my knowledge.

_________________________ Signature of the Candidate

*Compulsory

______________ Date

__________________________________ Signature of the Centre Head (With Seal and Date)