Janardan Rai Nagar Rajasthan Vidyapeeth

(Deemed to be University)
Pratap Nagar, Airport Road, UDAIPUR
www.jrnrvu.edu.in

APPLICATION FORM FOR REFUND OF FEE

PHOTOGRAPH

1. Name of the Applicant :

2. Father’s Name:

3. Name of the Course:

4. Year of taking Admission:

5. Year of Completion of Course :

6. Enrollment No. :

7. Name of the study Centre:

8. Details of Fee Paid to the University :

Semester I :Amount (……………………………..)

Semester II : Amount (……………………………..)

Semester IIII :Amount (……………………………..)

Semester IV : Amount (……………………………..)

Semester V :Amount (……………………………..)

Semester VI:Amount (……………………………..)

Semester VII :Amount (……………………………..)

Semester VIII :Amount (……………………………..)

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9. Details of Mark sheets

Semester I : S.no (……………………… ) Date: (……………………………..)

Semester II :S.no (……………………… ) Date: (……………………………..)

Semester IIII :S.no (……………………… ) Date: (……………………………..)

Semester IV :S.no (……………………… ) Date: (……………………………..)

Semester V :S.no (……………………… ) Date: (……………………………..)

Semester VI:S.no (……………………….) Date: (……………………………..)

Semester VII :S.no (……………………… ) Date: (……………………………..)

Semester VIII :S.no (……………………… ) Date: (……………………………..)

10. Details of Provisional Certificate (If Received):

S.No of Provisional Certificate : (……………………………..)

Date of Issuance of Provisional Certificate: (……………………………..)

11. Details of Degree (If Received) :

S.No of Degree: (……………………………..)

Date of Issuance of Degree: (……………………………..)

12. Present Residential Address:

13. Mobile no.: ……………………………………..

14. E mail Id: ……………………………………….

15. Aadhaar Card No.: ……………………………………

16. Details of Bank Account in which the refund of Fee has to be Transferred:

Account No.: ………………………………….

Name of the Account Holder : …………………………………………………….

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 Name of the Bank:……………………………………………………………………

Branch:…………………………………………………………………………………

IFSC Code:…………………………………………………………………………….

17. Whether the applicant took any employment on the basis of the Degree in
Engineering. If Yes Provide Details:

………………………………………………………………………………………………
………………………………………………………………………………………………
………………………………………………………………………………………………

18. Whether the applicant took any higher qualification has been taken on the basis
of the Degree in Engineering. If Yes Provide Details:

………………………………………………………………………………………………
………………………………………………………………………………………………
………………………………………………………………………………………………

SIGNATURE

DECLARATION

I…………………….………………S/0………………………………………………………….
R/o………………………………………………………………………………………………
declare that the information provided above is true and correct. I am submitting my
original Marksheets/ Provision Certificate/Degree along with the application for
cancellation and the same may be cancelled in the records of the University. I
undertake not to make any use of the Degree in future for the employment or attaining
higher education. The refund may be transferred to the account details provided by
above.

SIGNATURE

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The following Documents are to be submitted along with the Form:

1. Original Mark sheets of all the semesters issued by the University

2. Original Provisional Certificate if Issued by the University
3. Original Degree if issued by the University
4. Photocopy of the Identity Proof (Aadhaar Card/ voter Id Card) of the
applicant
5. Photocopy of the Passbook/Bank Statement of the account in which the
refund has to be transferred.
6. Original/Photocopy of all the Receipts of fee paid to the Deemed to be
University.

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