Form for Refund of Caution Deposit

Please completely fill in this Form, sign it and submit it to the Registrar’s Office by 31 May 2016. The information
provided will be used to transfer your caution deposit, after making all recoveries, to your bank account. You
may send the Form through DA-IICT email also.

1 Name of the Program : B-Tech (ICT)

2 Student ID No. : 201201192
3 Student Name : Jayant Pareek
Name of the Bank in
4 which you have your
Account
:
State Bank of Bikaner and Jaipur
5 Bank Account No. : 61157603574
6 Bank’s Address : Jassusar Gate, Bikaner - 334001
7 Branch Code : 010312
Single Account
8 Account Type (Please ) :
Joint Account ✔
Account held in the 1 Jayant Pareek
9 Name(s) of (as per the :
records of the Bank) 2 Chiranji Lal Tiwari

10 NEFT IFSC / RTGS Code : SBBJ0010312

11 MICR Code : 334003312
12 Father’s Name : Chiranji Lal Tiwari
13 Mother’s Name : Suman Pareek
Your e-mail ID
14
(Other than DA-IICT)
: jayantpareek12@gmail.com
15 Contact Nos. : +91-9558159828, +91-7568140921
Declaration
I declare that:
• The information given above in this form is complete and correct. I will be solely responsible
for any error that occurs due to inaccuracy of the details provided in this form. ✔
• I will inform the DA-IICT immediately about the changes in my bank account details, if any. ✔

Signature of the Student

Date
Digitally signed by Jayant Pareek

Jayant Pareek
DN: cn=Jayant Pareek, o=DA-IICT,
ou=DA-IICT, 30-May-2016
D D M M Y Y Y Y
email=201201192@daiict.ac.in, c=IN
Date: 2016.05.30 12:07:45 +05'30'