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Hkkjrh izkS ksfxdh laLFkku dk kh fgUnw fo ofo ky okjk. klh INDIAN INSTITUTE OF TECHNOLOGY BANARAS HINDU UNIVERSITY VARANASI Academic Section Consent Form for the FIRST Convocation Roll No. Department Programme of Study UG B. Tech. /B. Pharm./IDD/IMD PG Academic Programme completed on date 4. NO DUES Cleared YES / NO Date of last examination Name of the Student in English Name of Student in Hindi Current Postal Address Pin Code e-mail id Mobile No. Tick one of the following boxes applicable to you YES I shall attend the Convocation and receive the Degree in person. A Bank Draft /IIT BHU Cash Challan No. dated for Rs. Hkkjrh izkS ksfxdh laLFkku dk kh fgUnw fo ofo ky okjk. klh INDIAN INSTITUTE OF TECHNOLOGY BANARAS HINDU UNIVERSITY VARANASI Academic Section Consent Form for the FIRST Convocation Roll No* Department Programme of Study UG B. Tech. /B. Pharm*/IDD/IMD PG Academic Programme completed on date 4. NO DUES Cleared YES / NO Date of last examination Name of the Student in English Name of Student in Hindi Current Postal Address Pin Code e-mail id Mobile No* Tick one of the following boxes applicable to you YES I shall attend the Convocation and receive the Degree in person* A Bank Draft /IIT BHU Cash Challan No* dated for Rs. 1100/- is enclosed herewith as fee for receiving the Degree in person* if you are opting to attend the FIRST Convocation in person you will compulsorily have to attend the Convocation rehearsal scheduled on July 9 2013 NO I shall not be able to attend the Convocation* Bank Draft should be drawn in favour of The Registrar IIT BHU payable at SBI IT BHU Varanasi a Hostel accommodation required Tick one Yes No b Number of person s accompanying Date //2013 Signature of the Student if there is any variation in the name you must write separately through SPEED POST duly supported by a copy of the last Degree/Certificate. The Degree will be awarded in trilingual Sanskrit Hindi English. The change of name in Hindi should not be made unless you are sure of its correction* If you are unable to submit this form in DOAA Office in person you may post it along with Bank Draft and other enclosures if any through SPEED POST at the following address so as to reach us latest by June 25 2013 and send scanned copy through e-mail* The Dean Academic Affairs Indian Institute of Technology Banaras Hindu University Varanasi-221005 Uttar Pradesh INDIA PS For any queries related to Convocation please contact Academic Section IIT BHU Varanasi Tel*No* 0542-6702067 6702070 e-mail academics itbhu. Tech. /B. Pharm*/IDD/IMD PG Academic Programme completed on date 4. NO DUES Cleared YES / NO Date of last examination Name of the Student in English Name of Student in Hindi Current Postal Address Pin Code e-mail id Mobile No* Tick one of the following boxes applicable to you YES I shall attend the Convocation and receive the Degree in person* A Bank Draft /IIT BHU Cash Challan No* dated for Rs. 1100/- is enclosed herewith as fee for receiving the Degree in person* if you are opting to attend the FIRST Convocation in person you will compulsorily have to attend the Convocation rehearsal scheduled on July 9 2013 NO I shall not be able to attend the Convocation* Bank Draft should be drawn in favour of The Registrar IIT BHU payable at SBI IT BHU Varanasi a Hostel accommodation required Tick one Yes No b Number of person s accompanying Date //2013 Signature of the Student if there is any variation in the name you must write separately through SPEED POST duly supported by a copy of the last Degree/Certificate.

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