APPLICATION FOR PHOTOCOPY OF EVALUATED ANSWER SCRIPT (S) FOR SELF-INSPECTION AND/OR REVIEW

To
Application No: 0004317
The Controller of Examinations
University of Calcutta
87/1 College Street
Kolkata - 700 073.

Sir,
i). I would like to apply for re-examination of 1 paper for which I am furnishing my particulars as hereunder and remitting
Rupees One Hundred Ten only (Rs. 110 /-) herewith.
ii). I would like to obtain photocopy of 1 number of answer script for the purpose of my self -inspection for which I am
furnishing my particulars as hereunder and remitting Rupees Five Hundred only (Rs. 500/-) herewith.

a) Name (In Block letters) : SHUBHOJIT CHAKRABORTY

b) Contact Address : Kora Babu para,Madhyamgram,P.O.-Kora Chandigarh,North 24 PGS,KOLKATA-700130
c) Mobile No. : 9038138729
d) Name of the Examination and Year : B.Sc. PART-III(General) Examination - 2019

e) Roll No. : 3142-65-0115

(Photocopy of Admit card shall have to be attached)
f) Registration No. and session : 142-1121-1859-15

(Photocopy of Regn. certificate shall have to be attached)

g) Photocopy of evaluated answer script in Subjects and Paper sought for self-inspection.

Subjects and Paper/s (to be written in abbreviated form as shown in the marksheet)
MTMG(4)

(Photocopy of marksheet shall have to be attached)

h) Subjects and papers sought for re-examination of answer script under the relevant
Regulations of the University.
MTMG(4)

i) Indicate subjects and papers sought for both re-examination and self-inspection
MTMG(4)
DECLARATION
I declare that the above statements made by me are true to the best of my knowledge and belief and if any of
the statements is found to be false, my application shall liable to be rejected by the University without any
intimation to me and I shall not claim refund of fees in any event.
Date : ..........................................................
N.B.
Full Signature of the Examinee
1. Last date of submission of form to the College by the Student - 29/08/2019
2. Students are required to submit the form along with fees to their College only.

Countersigned by the Principal .........................................................................., College

Enclosed: Please Tick( ü)
i) Photocopy of Admit Card
ii) Photocopy of Registration Certificate
iii) Photocopy of Marksheet

CHALLAN COPY FOR STUDENT

BANGABASI COLLEGE
Received an amount of Rs.610.00/- from SHUBHOJIT CHAKRABORTY having Registration No. 142-1121-1859-15 and Roll
No.3142-65-0115 as re-examination and/or FSI application fees for B.Sc. PART-III(General) Examination - 2019

Date (Signature of dealing person with college seal)