Sr. No.
: 25987 (for office use only)
GURU JAMBHESHWAR UNIVERSITY OF SCIENCE & TECHNOLOGY,
HISAR
(HOSTEL STAY FORM for session 2025-26 )
Date of Admission : 21-07-2025
Hostel : Boys Hostel 4
Name : DIKSHANT
Mobile No. (Self) : 9588795220
Email : dikshantgadhwal001@gmail.com
Father`s Name & Mob. : SANDEEP KUMAR - 9812732401
Mother`s Name & Mob. : SHARDA DEVI - 9812432401
Department : Department of Mathematics
Course : Integrated B.Sc. (Physical Sciences) - M.Sc. Mathematics
Year :1
Registration No. : 2509115
Date of Birth : 07/10/2006
Category : General
Permanent Address : 656 , vpo Bhodia Khera FATEHABAD Haryana 125050, Bhodia Khera, Haryana
Visitor`s Details : Navdeep kumar - 9812332401 - V.P.O BHODIA KHERA , FATEHABAD
: Sandeep kumar - 9588795220 - V.P.O BHODIA KHERA, FATEHABAD
Local Guardian`s Details : Sonu bala - 9812432401 - V.P.O BHODIA KHERA, FATEHABAD
(In case details of local guardian is not provided by the resident, the Chairperson/Director of the concerned dept. will be considered as local
guardian for residents of Girls Hostel.)
Blood Group : A+
Aadhaar No. : 7019 3073 4479
Account Details
Account No : 6504000100067405
IFSC Code : PUNB0650400
Bank Name : PUNJAB NATIONAL BANK
Old Residence Details (if you are an old resident of the Hostel)
Hostel : ___________________________________________
Room No. : ___________________________________________
Session : ___________________________________________
Dues if any : ___________________________________________
Recommendation of Coordinator/Warden ......................................................................... Signature ..................................
I undertake to abide by all the hostel rules and regulations of the University failing which disciplinary action may be
taken against me. I will not keep iron rod/ weapon/ arms of any kind in the hostel. I will not keep and use heater/electric
iron/induction etc. Further, I will vacate the hostel any time as per requirement of the University. The undertakings and
consents about not involving in activities such as ragging, etc. are enclosed. I agreed to abide by the rules and regulations of
GJUS&T, Hisar in letter spirit. Further, No FIR against me in any criminal cases has been lodged till date.
Father/Guardian`s Signature Counter Signature (with seal) Director/Chairperson Signature of the Applicant
Date : .........
Note : Please submit Medical Fitness Certificate with this application form, if you are fresh student.
CERTIFICATE FROM THE CHAIRPERSON/HEAD OF
DEPARTMENT
It is recommended that Mr./Ms. DIKSHANT Son/Daughter of Sh. SANDEEP KUMAR is a bonafide student/research
scholar/project fellow of this Department and may be admitted to the University Hostel. I certify that the address of the
applicant given above is the same as given in the admission form of the Department and it is not located within 30 kms.
(Applicable for Girls) and 40 kms. (Applicable for Boys) radius of Hisar city. In case the applicant leaves the
Department or his/her name is struck off on account of non-payment of dues or other reason, I shall inform the Chief
Warden. I shall not issue the Roll No. of the Examination/provisional certificate/transcript of degree to the applicant
unless he/she produces a NO DUES CERTIFICATE from the Coordinator/Warden/Dy. Chief Warden/Chief Warden.
His/Her position in the Entrance Merit List is ________________________ . I shall also share the responsibility in case
of any need by hostel administration in any emergency regarding him/her.
Signature Chairperson
(Supervisor) (In case of Ph.D. Student) (with seal)
UNDERTAKING ABOUT RAGGING
I have read page 37 of the University prospectus (2025-26) regarding the direction and `Zero Tolerance` about ragging. I
pledge to abide by the directions and guidelines of Supreme Court, Government of India, UGC, State Government and
Guru Jambheshwar University of Science and Technology about ragging. If at any stage of my stay in the hostel I am
found involved in the incident of ragging I will accept appropriate punishment, fine or both from the university
authorities & be ready to face legal action.
Signature of the applicant with date
UNDERTAKING ABOUT NON-CONSUMPTION OF SMOKING,
ALCOHOL AND DRUGS
I pledge to abide by the directions and guidelines of Supreme Court, Government of India, State Government and Guru
Jambheshwar University of Science and Technology about abuse of drugs and alcohol in the University campus. If at
any stage of my stay in the University and hostels, I am found under the influence, possession or consumption of
Drugs/alcohol/smoking I will accept appropriate punishment, fine or both from the university authorities & be ready to
face legal action.
Signature of the applicant with date
UNDERTAKING FROM PARENTS ABOUT ALCOHOL AND DRUGS ABUSE
My son/daughter has no past record of indulgence in any type of drug abuse or consumption of alcohol. I fully take the
responsibility that he/she will continue to maintain non indulgence in drugs and alcohol throughout his/her stay in the
University and hostel. If at any stage of his/her stay in the University and hostels, he/she found under the influence,
possession or consumption of Drugs or alcohol I will accept appropriate punishment, fine or both imposed on my ward
by the university authorities.
Signature of the parents with date
Mother ..................................................
Father ...................................................
CERTIFICATE FROM THE CHAIRPERSON/HEAD OF DEPARTMENT
(For female employee only)
It is recommended that Ms. DIKSHANT D/W of Sh. SANDEEP KUMAR is working as ________________________
in this department and may be allowed room in WWH. I certify that the address of the applicant is the same as given in
her application and it is not located withing 30 KM radius of Hisar city. In case the applicant leaves the department, I
shall inform the Chief Warden. I shall not clear her last payment/salary/benefit/issue experience certificate of the
applicant unless she produce a NO DUES CERTIFICATE from the Coordinator/Warden/Deputy Chief Warden/Chief
Warden. I shall also share the responsibility in case of need by Hostel Administration due to any emergency regarding
her/him.
Chaiperson/Head of the Department with Seal
UNDERTAKING FROM PARENTS/SPOUSE
I ........................................... F/M/H of Mr./Ms ....................................................... is giving my consent to stay in the
hostel. My ward/spouse will abide by all the rules and regulations of the hostel. Further, I will share the responsibility of
my ward/spouse in case of any emergency as and when required.
Signature of Parents/Spouse
Date .............................
