APPLICATION FOR REVIEW

To
Application No: 0041902
The Controller of Examinations
University of Calcutta
87/1 College Street
Kolkata - 700 073.

Sir,
I would like to apply for re-examination of 1 Paper for which I am furnishing my particulars as hereunder and
remitting Rupees One Hundred Ten only (Rs. 110 /-) herewith.

a) Name (In Block letters) : DIPAN ADAK

b) Contact Address : GARMIRZAPUR MASHILA HOWRAH

HOWRAH,711302
c) Mobile No. : 9681877875

d) Name of the Examination and Year : B.Sc. SEMESTER - V (HONOURS) Examination, 2022 (Under CBCS)

e) Roll No. : 203432-21-0007

f) Registration No. : : 432-1111-0385-20

g) Subjects and papers sought for re-examination of answer script under the relevant
Regulations of the University.
CMSA-DSE-A1

DECLARATION

I declare that the above statements made by me are true to the best of my knowledge and belief and if any of
the statements is found to be false, my application shall liable to be rejected by the University without any
intimation to me .

Date : 16/05/2023 ..........................................................

N.B.
Full Signature of the Examinee

1. Last date of submission of form to the college by the student - 23/05/2023

Countersigned by the Principal .........................................................................., College

Enclosed: Please Tick( )
i) Photocopy of Admit Card
ii) Photocopy of Registration Certificate
iii) Photocopy of Gradesheet

RECEIPT COPY FOR STUDENT

Received an amount of Rs.110.00 from DIPAN ADAK having Registration No. 432-1111-0385-20 and Roll No. 203432-21-0007 for
re-examination B.Sc. SEMESTER - V (HONOURS) Examination, 2022 (Under CBCS)

Date (Signature of dealing person with college seal)