Direct Admission of Students Abroad (DASA) 2018

(A Scheme of Ministry of Human Resource Development, Government of India)

COORDINATING INSTITUTION
eksrhyky usg: jk’Vªh; ÁkS|ksfxdh laLFkku
bykgkckn
bykgkckn & 211004 ¼m0Á0½ Hkkjr
Motilal Nehru National Institute of Technology Allahabad
Allahabad – 211004 (UP) INDIA

REFUND REQUEST FORM

Name of the Applicant :
DASA-2018 Application ID :
Applied Category : CIWG / Non-CIWG (SAARC) / Non-CIWG (Non-SAARC)

Amount deposited in _________ (INR / USD).

Amount deposited for category
Status of the candidate
: Amount ______________________________.
(Attach complete payment proof separately)
: Tick mark the appropriate box
1) Seat is not allotted in any round.
2) Seat Allotted in ____ round, but declined / No
response is given within stipulated time.
4) Fees deposited for Non-CIWG category but
allotted a seat in CIWG category.
6) Withdrawal (Mention the date of withdrawal on
DASA-2018 through email along with stage at
which withdrawn)
Date :________________________
Stage :________________________

Account details for refund

(Preferably the account mentioned at the time of form filling or Indian account instead of foreign account)

Name of Account Holder :

Bank Account Number :
Bank Name :
Branch Name :
IFS Code :
SWIFT Code (in case of Foreign account) :

Date: Signature

Phone: 0532 227 10 44, 51, 47 Website: www.dasanit.org Email: dasa2018@mnnit.ac.in

Pg. 1/1