N.I.T.

HOSTELS: TIRUCHIRAPPALLI - 620 015

APPLICATION FOR VACATING HOSTEL AND MESS REFUND
Please type. SHOULD NOT fill up the application in hand writing

Name

Rubal Bagde

Roll No

1501097

Course

IIM PGP 2015-2017

Branch

MBA

Hostel Name

OPAL D

Room No

126

Name of the SBI Bank

SBI NIT Trichy

Communication Address

SBI Bank A/c No

Email Id

Rubal.p15097@iimtrichy.ac.in

9860694681
-

Mobile No
Phone No

Hostel Fees Details (Attach a Copy of MIS Hostel Fees Printout)

Receipt No
Date

Semester

Amount

Date of Vacating the Hostel Room: JUNE 11,2016

Details of the Furniture available in the room:
Table

Yes

Chair

Yes

Mess Details
Mess Name
Signature of the Mess Manager
Signature of the Student

Cot

Yes

Fan

Yes

Tube Light

Yes

Date of Mess Leaving

I hereby request Hostel Administration to refund my hostel dues after deducting Rs.300 towards mess
Workers Welfare Fund and Rs.300 towards processing fees.

Signature of the RSC/Steward

Signature of the Warden
(For Office Use)
Refund Amount (Subject to Audit) : Rs.--------------------/
Signature of the Accountant

Signature of the D.R. (Hostels)