DAKSHINA BHARAT HINDI PRACHAR SABHA, MADRAS

THANIKACHALAM ROAD, T. NAGAR, CHENNAI-600 017

APPLICATION FORM FOR “WITH-HELD” CLEARING
(FORM DOWNLOADED FROM WEBSITE)

The Hall-Tickets with a note of “Your Result will be kept WITH – HELD” due to insufficient previous
examination pass details or exemption (choot) details. Kindly furnish the details of the previous exam. year,
month and Roll No. on the specified column and send this form to THE SECRETARY FOR EXAMINATIONS,
D.B.HINDI PRACHAR SABHA, THANIKACHALAM ROAD, T.NAGAR, CHENNAI-17, within 10 days of publication
of results.

EXAMINATION SECRETARY

1. CANDIDATE’S NAME : ………………………………………………………………………….

2. EXAMINATION APPEARED : ………………………………… ROLL NO. …………………………..

3. PREVIOUS EXAMINATION
PASSED DETAILS : EXAM. : ………………………………… ROLL NO. …………………………..

MONTH …….………….……. YEAR ……………………….………

4. OBTAINED EXEMPTIONS
IF ANY :

SIGNATURE OF THE CANDIDATE

MOBILE NO. ………………………………………..

POSTAL ADDRESS ……………………………………………………..…….

…………………………………………….…………….

………………………… PIN CODE ………………….