For Office Sr. No…………..

…………
Use Only
Date: ………………..…..

SANT LONGOWAL INSTITUTE OF ENGINEERING & TECHNOLOGY

LONGOWAL, DISTT. SANGRUR
(DEEMED TO BE UNIVERSITY U/S 3 OF UGC ACT 1956)
(To be deposited in Account Section within
APPLICATION FOR 1. Refund of Caution Money 3 year from the pass of last exam)
2. Admission Category (Please Tick One Option) PMS (SC Punjab) / PMSSS / TFW /OBC /GEN

Note: PLEASE FILL UP THE FORM IN CAPITAL LETTER

Name of the Student Mr./Ms………………………………..…….………......Father’s Name SH. ……………..……………………….………………

(IN CAPTIAL LETTERS) (IN CAPTIAL LETTERS)

Previous Registration No. in case of Promote Registration No. in case of Direct Entry
Discipline Trade Registration No. Batch Discipline Trade Registration No. Batch
Certificate Certificate
(if promoted to Diploma)
Diploma/ICD Diploma/ICD
(if promoted to Degree)

Degree Degree
Last Exam passed
PG/MBA/PhD
(Month & Year)
Current Registration No (If Presently Studying in SLIET):

Permanent Address (IN CAPTIAL LETTERS)……………………………………………………………………………………………………………………..

……………………………………………………………………………………………………………………………………………………………………………..………..
……………………………………………………………………………………………………………………………………………………………………………………….
Land Line Phone Number……………………………………………………… Mobile No (Self)...…………………………………………………………
Correspondence Address…………………………..…………………………………………………………………………………………………………………..
(On which the Caution Money is to be sent)……………..…………………………………………………………………………………………………..
………………………………………………………………………………………………………………………..
Account No IFSC Code
Caution Money may please be transferred in My Central Bank of India
SB A/C Other Bank
Enclose: 1. Please attach Photocopy of your Bank Pass Book
(Where Account No, Name, Branch Address & IFSC Code is mentioned)
2. Copy of Notice (In Case of Name Struck Off)
Signature of Student
With Date
The above student is going to leave the Institute, Please mention if anything due against him/her. In case nothing due
against the student please write “No-Dues” clearly.

DEAN (SFW)
D & C Register No……………….

Page 1 of 5
 ACCOUNT SECTION

NO DUES CERTIFICATE
Name of Department…………………………….
Lab-1 Lab-2 Lab-3 Lab-4 Lab-5 Lab-6

Concerned Lab-7 Lab-8 Lab-9 Lab-10 Lab-11 Lab-12

1. Department Labs./
Workshop Workshop Workshop Workshop Workshop Workshop Workshop

Sr. Signature of Sign. Of HOD/

Department Dues if any No-Dues
No. Dealing Hand Section In charge
Concerned Department in
2. Ref. to Sr. No. (1) above
(To which the student was admitted)

3. Library
Boys/Girls Houses
4.
(Hostler / Day Scholar)
Please Tick

5. Sports Department

6. N.C.C (For Degree only)

Scholarship Cell Applicable
7. in case of -PMS (SC Punjab) /
PMSSS / TFW

8. Academic Section

PRE-RECEIPT

Received a sum of Rs……………………….. (Rupees………………………………………………….……………………………………….only) from the

Director, Sant Longowal Institute of Engineering & Technology, Longowal on account of Caution Money through Demand
Draft issued by Central Bank of India, Longowal.

Signature on Revenue Stamp Revenue Stamp

Name……………………………………………………………
Registration No…………………………………………….

Page 2 of 5
 ACADEMIC SECTION
NO DUES CERTIFICATE
Name of Department…………………………….
Lab-1 Lab-2 Lab-3 Lab-4 Lab-5 Lab-6

Concerned Lab-7 Lab-8 Lab-9 Lab-10 Lab-11 Lab-12

1. Department Labs./
Workshop Workshop Workshop Workshop Workshop Workshop Workshop

Sr. Signature of Sign. Of HOD/

Department Dues if any No-Dues
No. Dealing Hand Section In charge
Concerned Department in
2. Ref. to Sr. No. (1) above
(To which the student was admitted)

3. Library
Boys/Girls Houses
4.
(Hostler / Day Scholar)
Please Tick

5. Sports Department

6. N.C.C (For Diploma & Degree)

Scholarship Cell Applicable
7. in case of -PMS (SC Punjab) /
PMSSS / TFW

8. Academic Section

Signature of Student……………………….…………………
Name…………………………………………………………………
Registration No………………………………………………….
Roll No………………………………………………………………

Page 3 of 5
 STUDENT COPY
NO DUES CERTIFICATE
Name of Department…………………………….
Lab-1 Lab-2 Lab-3 Lab-4 Lab-5 Lab-6

Concerned Lab-7 Lab-8 Lab-9 Lab-10 Lab-11 Lab-12

1. Department Labs./
Workshop Workshop Workshop Workshop Workshop Workshop Workshop

Sr. Signature of Sign. Of HOD/

Department Dues if any No-Dues
No. Dealing Hand Section In charge
Concerned Department in
2. Ref. to Sr. No. (1) above
(To which the student was admitted)

3. Library
Boys/Girls Houses
4.
(Hostler / Day Scholar)
Please Tick

5. Sports Department

6. N.C.C (For Diploma & Degree)

Scholarship Cell Applicable
7. in case of -PMS (SC Punjab) /
PMSSS / TFW

8. Academic Section

Signature of Student……………………….…………………
Name…………………………………………………………………
Registration No………………………………………………….
Roll No………………………………………………………………

Page 4 of 5
 RTGS DETAIL
FILL ALL THE DETAIL IN CAPITAL LETTERS

NAME OF STUDENT

TRADE/REGN. NO.

FATHER NAME

PERMANENT CONTACT NUMBER

BANK NAME

STUDENT BANK ACCOUNT NO.

IFSC CODE

The particular mentioned above are correct and undertake to bear any loss of transaction
through RTGS personally.

SIGNATURE OF STUDENT

Page 5 of 5