RAJIV GANDHI INSTITUTE OF PETROLEUM TECHNOLOGY JAIS, AMETHI,

APPLICATION FOR CANCELLATION & WITHDRAWAL OF ADMISSION SESSION: ______

Date: To,

The Director / Registrar Rajiv Gandhi Institute of Petroleum Technology Jais, Amethi-229304 Uttar Pradesh

Through: a) Associate Dean (Academic Affairs)

b) Chairman UG/PG Admission Committee

c) Head of Department /Concerned Student’s PhD Supervisor

Sir,

I was s h o rt l is ted & s ec u r ed admission to the B. Tech. /M. Tech. /Ph. D./MBA/Others Program’s in your Institute on ______. I would like to cancel and withdrawal my candidature it due to the following reasons:

______

1) Name of the Candidate: Ms. / Mr. (IN BLOCK LETTERS) (Name) (Surname)

2) Father’s Name: Mr. / Dr.

3) RGIPT Registration No.:

4) IIT JEE/GATE/CAT Roll No.:

Mubarakpur, Mukhetia, Bahadurpur, Post: Harbanshganj, Jais, Amethi-229304 (Uttar Pradesh) Phone: 0531-3250022| Website: www.rgipt.ac.in

RAJIV GANDHI INSTITUTE OF PETROLEUM TECHNOLOGY JAIS, AMETHI, UTTAR PRADESH

5) Residential or Correspondence Address (As registered in the RGIPT Registration Form) ______PIN Cell No.: +91 E-Mail:

6) Fee Paid (`) (in words) _ Online Transaction No. / D. D. No. ______Dated ______Banker ______

(a) I am enclosing the Xerox of the Fee Receipt (No. Dated ) (b) I am returning my Identity Card (Original) (c) I am also returning the Study Materials (Strike out whichever is not applicable)

Kindly direct to return my original documents and refund the fees paid as per the rules.

Thanking you,

Yours truly,

Signature of Candidate FOR OFFICE USE ONLY

Amount Paid (`)

Amount deducted (`)

Amount Refunded (`)

Cheque No. & Date

Bank Particular

Mubarakpur, Mukhetia, Bahadurpur, Post: Harbanshganj, Jais, Amethi-229304 (Uttar Pradesh) Phone: 0531-3250022| Website: www.rgipt.ac.in

RAJIV GANDHI INSTITUTE OF PETROLEUM TECHNOLOGY JAIS, AMETHI, UTTAR PRADESH

Reference AICTE Guidelines No - AICTE/Legal/04(01)/2007, April 2007 and Circular No 698 dated 24th August 2007 issued by Pravesh Niyantran Samiti, .

Any candidate who has been admitted to RGIPT may cancel admission by submitting an application in duplicate in the prescribed form and may request for refund of fees. The refund of fees as applicable shall be made in due course. Refund shall be made after deduction of the cancellation charges as shown below.

Sr. No. Situation Refund 1. Request Received before date of start Entire fee less ` 1000/- of academic session & seat could be filled by the Institute before the cutoff date

2. Request received after start of Entire fee less the Total Fees academic session & Seat could be (Tuition Development & Hostel filled by the Institute by waitlisted Fee) on pro rata basis candidates 3. Request received after start of No Refund (except Security Deposit) academic session & seat could not be filled by the Institute

Note:

 Entire amount of Security / Caution Money Deposit is to be refunded to candidate.

 For calculation of amount on the pro-data basis, one month shall be treated as one unit e.g. if the candidate cancels admission on third day after start of Academic Session & the seat is filled before cutoff date, then cancellation charges will be the higher amount of ( Total Fees ) / 12 or ` 10,000.00

 Any dispute will be subject to the jurisdiction of the High Court of Raebareli only.

Mubarakpur, Mukhetia, Bahadurpur, Post: Harbanshganj, Jais, Amethi-229304 (Uttar Pradesh) Phone: 0531-3250022| Website: www.rgipt.ac.in