North Eastern Regional Institute of Science & Technology

[Deemed to be University]
[Under Ministry of Education, Govt of India]
Nirjuli – 791 109 ::: Arunachal Pradesh

APPLICATION FOR FINAL WITHDRAWAL FROM THE INSTITUTE

(FOR POST-GRADUATE STUDENTS ONLY)

1. Name of student (in block letters): _____________________________________________

2. Roll No. : _____________________________________________

3. Regn. No. : _____________________________________________

4. Module/Programme : _____________________________________________

5. Department : _____________________________________________

6. Aadhaar No :_______________________________________________

7. Reasons for withdrawal : _____________________________________________

I have completed/relinquished my studies in NERIST _______________(mention month &

year) and request you to refund my deposit/caution money. The amount of caution money may
kindly be deposited in my Account No.____________________________ at __________________
Branch of ____________________________________(name of the Bank).

Date: Signature of the Students

Mobile No.__________________

Email: _______________________

Address:_____________________________
____________________________________
____________________________________
____________________________________

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 NO DUES CERTIFICATE
i) Name of student (in block letters): _______________________________________________

ii) Roll No.______________________________Regn. No.______________________________

Signature of the student

______________________________________________________________________________

This is to certify that there are no outstanding dues against the student as per the details
given in the pre-page.

HOSTEL Warden (Block-________) Chairman, HMC, NERIST

In-Charge T&P Cell, NERIST Librarian, NERIST (Central Library)

Chairman, Gymkhana, NERIST In-Charge ET Cell, NERIST

Concerned Head of the Deptt., NERIST A.R/D.R(Academic),NERIST

______________________________________________________________________________
N.B.:
1. Identity Card should be returned to the PG Cell of the Academic Section for getting “No Dues
Certificate”.

2. No dues certificate should be submitted in original along with 02 (Two) Nos. photocopies to
the Academic Section.

3. All pass out students are required to pay Rs.1500/- for Original Certificate at the time of
submission of No Dues Certificate.

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