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Symbiosis Centre for Distance Learning, Symbiosis Bhavan, 1065 B, Gokhale Cross Road, Model Colony, Pune 411 016

(ACADEMIC Year July 2011) 3

To, The Director Respected Madam, I have enrolled at Symbiosis Centre for Distance Learning, Pune for the programs commencing from 1st July 2011. 3 My particulars are as follows: Name: ________________________________ Registration #: _____________

Program/Course enrolled: __________________ Specialization (if any): __________ Communication address: ______________________________________________ State: _________________ Contact #: ______________ Country: _______________________________

email id: _______________________________

Reason for cancellation: _______________________________________________ I am returning my Study Material as well as ID card & Admission letter: Yes/ No Dispatch details are as follows: Date: __________________ OR I am unable to return the Study material & ID card & I agree for deduction for the same from my refund amount (if any) as per SCDL Rules & regulations. Docket No: __________________


1. Late admissions i.e. students registered after 14 30 September 2011 3 are not entitled for refund of fees.

2. Student has to return the Study kit & ID card along with the Admission cancellation form; only after receipt of the Study material & ID card admission cancellation request will be processed. 3. The processing of approved refund request will require at least 5-6 weeks after receipt of the same at SCDL, Pune. 4. Admission cancellation request received after the 14 30th Sept 2011 3 will not be entertained (Please check the e-prospectus for admission cancellation policies and timeline which is uploaded on web site). 5. Refund Request should be forwarded to the above mentioned address in the form of hard copy only. 6. Admission cancellation requests will be entertained in the prescribed format and with in the due date only. Cancellation request will not be entertained through email or Fax. 7. SCDL will not be responsible for any postal delays. 8. Student will receive only refund of program fee paid by them, after deduction of 50% administrative charges on the paid amount. I request you to cancel my admission. I am aware that the registration fees is non refundable. The refund of the course fees paid by me till date will be as per the SCDL policy. I have read the instructions at the time of filling of the form. Student Signature: _________________ Date: _______________

For SCDL Use Only

Refund Request received on: ____________________________________________________ Refund Request Approved/Not Approved/Request withdrawn/ Other Remarks Remark: 1. _____________________________________________________ 2. _____________________________________________________