For Office Use Only

TO GET MATRICULATION EVALUATION FAIL/RE-APPEAR IN SEMESTER SEPT 2013 (Particulars in this kind are to be completed by the Candidate after studying the Syllabi & instructions) Last Time: 02/07/2013 Exam Fee: 3000/-

Sheet No: Roll No Centre Code

SPECIAL CHOICE OF 1ST/2ND TERM FROM T EP TE MB SER 2010 TO S EP TE MEGABYTES ER 2012

10

Region Name SEXUAL

Male Girl

CATEGORY: Fail Re-Appear

If perhaps Re-Appear in Subject with Practical, Do you wish to appear in Sensible Examination once again? Deaf & Dumb Disabled Blind

CERTAINLY

NO

PERSONAL OF CANDIDATE -In English.......................................................

Desired Centre Name

Insert Recent Devoid of Attested Passport size Female Photograph. USUALLY DO NOT STAPLE

1 .

2 .

In Punjabi.......................................................

Term of the Prospect in English (In Capital Letters) Dad's Name in English (In Capital Letters) Mother's Identity in The english language (In Capital Letters) DOB in Words:

Date of Birth. Regn. No .

Particular date

Month

Year

Name of the Candidate (In Punjabi)

________________________________________ Father's Brand (In Punjabi) _____________________________________________ Mother's Name (In Punjabi)

In case you are Unable to write, do you want article writer? (Attach Certificate)

_____________________________________________

Charge Details: place: Fee Sum in Rs Receipt No . Dated

YES

NO

A ddres t............................................................................................................................................................................................................ Block....................................... Teh................................. Distt................... Phone Number with A SEXUALLY TRANSMITTED DISEASE Code....................................... Mobile No .................... Email:..................................................................................................

Medium

Punjabi

Hindi...

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