ASSAM ENGINEERING COLLEGE Paste recent

GUWAHATI, JALUKBARI – 781 013 coloured

PROJECT: TEQIP-III Passport size
GATE FEE REFUND photo

FORM-1: APPLICATION FORM FOR GATE REGISTRATION FEE REFUND UNDER TEQIP-III
(Only for BE Final year student)
APPLICANT DETAILS
Name of Student (in BLOCK LETTERS)

Father’s/Husband’s name
Present Address (with PIN)

Email-id and Phone/Mobile No.

Date of Birth (DD/MM/YYYY)

PAN
Male/Female/Others
Nationality
Department & Institute Roll No.
GATE Registration No.
Payment details
Amount: Rs..............(Rupees......................................................
*attach self-attached photocopy of GATE receipt.
...................................................................................................)

Details of Savings Bank Account

Name:........................................................................................
Account No.:..............................................................................
Name of Bank:...........................................................................
IFSC No.:....................................................................................

Declaration by applicant:
 I hereby declare that the entries made in this application form are correct.

Full Signature of the applicant:

Signature & seal: Date:
Forwarded by Head of Department
TEQIP-III OFFICE USE

On recommendation of the Head of ....................................................Department, Assam Engineering College, the

GATE Registration fee refund of Rs.....................(Rupees.................................................................................................)
to Mr/Ms.......................................................................is approved.
Approval No.......................................................................................................

Dr Pradip Baishya Dr Atul Bora

Co-ordinator Principal
TEQIP-III Assam Engineering College