ST.

XAVIER'S COLLEGE [AUTONOMOUS] KOLKATA

30, MOTHER TERESA SARANI (PARK STREET), KOLKATA - 700 016

MANDATE FORM FOR REFUND OF ADMISSION CANCELLATION

Application No: AC13521

Student Name : SOMSHANTO GHOSH

Department : ARTS & SCIENCE

Course : CMSA

College Roll Number : 513

Mobile No. : 9820949345

Email ID : somshanto.ghosh@gmail.com

Name (As in Bank Account) : SANTANU GHOSH

Name of the Bank : AXIS BANK

Name of the Branch : DUNLOP

Address of the Branch : AXIS BANK LTD, DUNLOP, KOLKATA - 700109

Account Number : 236010100168328

Type of Account : SB

IFS Code : UTIB0000236

I understand that the refund will be done on the basis of the information provided above.

Date : 03/09/2022 .....................................

Signature of Student

Please attach scan copies of the following:    1. Admission Fee Receipt

    2. Provisional Admission Form
3. Scan copy of the 1st page of Passbook containing the A/C number, IFS Code and
   
    other bank details or a Cancelled Cheque.

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For Office Use

Verified by :  

Signature of Office Staff Signature of Principal / Vice-Principal