CONSENT FORM (FOR THE GARDUANDS)

Fac ulty/De partme nt/Colle ge : BHU Main Campus (Fac ulty of Ayurve da)

FOR RECEIVING THE DEGREE / MEDALS

For The S e s s ion 2022-23

Sir/Madam,
I wish to at t end t he 103rd Convocat ion of t he Universit y in person.
Relevant informat ion about myself is given below
Name of S tude nt: ABHIS HEK KUMAR DUBEY

Name of Fathe r: S ham bhu Nath Dubey

Name of Mothe r: Asha Dubey

Cours e : B.N.Y.S

Ye ar of Pas s ing : 2022-23

Examination Roll No : 16161RG011

Enrolme nt No:

C/0 S hri S ham bhu Math Dubey Ashok Nagar S atani

Full Addre s s : S arai, Bhrigu Ashram Ballia-277001 Uttar Prade sh,
Distric t: Ballia, Pinc ode :277001

Email ID :(Pre s e nt) Abhis he k.dube y1996@ gmail.c om

Mobile No :(Pre s e nt) 7052118763

Payme nt ID: orde r_ NAERkhndc c Q72A

S tude nt ac ade mic robs

200
c harge s c onvoc ation:

Payme nt Date : 09/12/2023

I shall report to t he Facult y/Inst it ut e as per prescribed t ime schedule to

collect Ut t aria and Safa (part of Academic Cost ume) on payment of
prescribed fee.

Date : 10/12/2023

Your faithfully
(Full S ignature of the Graduand)
Note : Ple as e s ubmit the re c e ipt at your fac ulty / De partme nt / Colle ge for re c e iving the Uttaria and S afa.