Punjab

For Office Use Only
FOR MATRICULATION EXAMINATION FAIL/RE-APPEAR IN SEMESTER SEPTEMBER 2013 (Particulars in this form are to be filled in by the Candidate after reading the Syllabi & instructions) Last Date : 02/07/2013 Exam Fee : 3000/-

Sheet No : Roll No Centre Code

SPECIAL CHANCE FOR 1ST/2ND SEMESTER FROM S EP TE MB ER 2010 TO S EP TE MB ER 2012

10

District Name SEX
Male Female

CATEGORY:Fail Re-Appear

If Re-Appear in Subject with Practical , Do you want to appear in Practical Examination again? Deaf & Dumb Handicapped Blind

YES

NO

SIGNATURE OF CANDIDATE -In English.......................................................

Desired Centre Name

Paste Recent Without Attested Passport size Coloured Photograph.
DO NOT STAPLE

1.

2.

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

Name of the Candidate in English (In Capital Letters) Father’s Name in English (In Capital Letters) Mother’s Name in English (In Capital Letters)
DOB in Words :

Date of Birth. Regn. No.

Date

Month

Year

Name of the Candidate (In Punjabi)

________________________________________ Father’s Name (In Punjabi) _____________________________________________
Mother’s Name (In Punjabi)

If you are Unable to write, do you want writer ? (Attach Certificate)

_____________________________________________
Fee Details:- Place: Fee Amount in Rs Receipt No. Dated

YES

NO

A ddres s ............................................................................................. .... .................................................................................................... ....... Block.......................................Teh.................................Distt............... .... Phone Number with STD Code.......................................Mobile No. ................... Email : ............................................................................................ ......

Medium

Punjabi

Hindi