SELF ATTESTED APPLICATION FOR OPTING OUT OF JULY 2021 EXAMINATION

AND APPEARING IN NOVEMBER 2021 EXAMINATION

I son / daughter of born

on / / Registration Number Roll No.
wish to affirm and undertake as under:

1. I have made application for appearance in the July2021 examination.

2. I at my own free will have decided to Opt out of the July2021 examination and in lieu of the
same opting to appear in November2021 examinations due to following reason:

a. I declare that I am COVID-19 positive / have suffered from COVID -19 on/after 15th April,
2021

OR

b. I declare that my family members (grandparents / parents/ spouse/ children or siblings) living
in the same premises are COVID-19 positive / have suffered from COVID -19 on/after 15th
April, 2021

OR

c. I am affected due to lockdown as per the restrictions imposed by local / state government

OR

d. Examinations are not being held at my centre of examination due to lockdown

OR
e. Last minute change of my examination centre by ICAI without my request

3. I understand that by making this application I am withdrawing my July2021 examination

application and will NOT appear in the July2021 examination / remaining papers of July2021
examination.

4. I request that unexpired exemption if any valid for the July2021 examination be carried forward
for my appearance in November 2021 examinations.

5. I hereby agree that in case I do not appear in November 2021 examination I shall not claim any
benefits like carry over of exemptions / fees refund etc. for the same.

Signature of the Candidate:

Signature of the Parent (in case the candidate/examinee is a Minor):

Date: Place: