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Reg. No. ………………….

Receipt No._______Date______

Amount Rs. ________________

Examination Form Nov/Dec’2023

NAME OF COLLEGE:………………………………………………………………..

1. Name of Course & Branch:………………………………………………..

2. Name of Candidate:………………………………………………………..

3. Father’s Name:…………………………………………………………….

4. Address & Phone No:……………………………………………………………………..

………………………………………………………………………………………………

5. Subjects in which the candidate wish to appear in Regular Exam (Not Reappear )

Sr. I Sem. III Sem. V Sem. VII Sem. (B.Tech Only)

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I solemnly declare that I have not been debarred on account of detention in Sessional /attendance / U.M.C. /
misconduct/Non-deposit of fee etc for the above exam session.

(Signature of Candidate) (Signature of Class Mentor)

Date ___________

(Certificate by the Director)

Certified that ________________ is /was bonafide student of this institute and that the particular given
above by the candidate are correct as per the official records.

(Director)