økwshkík xufLkku÷kuSf÷ ÞwrLkðŠMkxe
[kt˾uzk, y{ËkðkË.
ÃkËðeËkLk Mk{kht¼Lkk økkuÕz {ìz÷Lke hf{ {kxuLke yhS
Application for Gold Medal to be awarded during Convocation
«rík,
hrsMxÙkh©e,
økwshkík xufLkku÷kuSf÷ ÞwrLkðŠMkxe, y{ËkðkË.
(1) økkuÕz {ìz÷ {kxu hf{ ykÃkLkkhLkwt Lkk{ :
(1) Name of person giving amount for Gold Medal :
(h) økkuÕz {ìz÷ {kxu hf{ ykÃkLkkhLkwt MkhLkk{w :
(2) Address of person giving amount for Gold Medal :
E-mail :- __________________________________ Mob. No. ___________________
Landline No. : (O) ________________________ (R) __________________________
(3) økkuÕz {ìz÷ {kxuLke hf{ :
(÷½w¥k{ Yk. 1,00,000/-)
(3) Amount of Gold Medal :
(minimum Rs. 1,00,000/-)
(4) økkuÕz {ìz÷ {kxuLke hf{Lkku rz{kLz zÙk^x Lktçkh íkÚkk íkkhe¾ :
(økwshkík xufLkku÷kuSf÷ ÞwrLkðŠMkxeLkk Lkk{Lkku y{ËkðkË ¾kíku [qfððkÃkkºk)
(4) D.D. No. & Date of amount for Gold Medal
(in favour of Gujarat Technological University payable at Ahmedabad)
D.D. No. : _________________________ Date : ___________________
(Ãk) çkUfLkwt Lkk{ :
(5) Name of Bank : _________________________________________________________
(6) økkuÕz {ìz÷ {kxuLkku nuíkw :
(y) rðãkþk¾k ______________________________________________
(çk) E÷uõxeð rð»kÞLkwt Lkk{ _______________________________________
(f) yLÞ fkuE nuíkw ____________________________________________
(6) Purpose for Gold Medal :
(a) Discipline ______________________________________________
(b) Name of Elective subject _________________________________
(c) For any other purpose ___________________________________
(7) økkuÕz {ìz÷ {kxuLke þhíkku (òu fkuE nkuÞ íkku) :
(7) Conditions for Gold Medal (if any) :
Date :
Place :
Signature