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PURVANCHAL HOSTEL
(446-A Talwandi Kota)
Hostel Admission Form
(Session: 201. - 201.)
(To be filled in by the applicant in his own handwriting clearly and carefully)
Important Instructions
For applying for hostel, Original Medical Certificate, Identity Proof and all essential documents at the time of
Admission.
No column should be left blank. Write N.A. if not applicable.
All the details should be filled in Block Capital Letters
Undertaking Form is to be signed by the candidate with blue/ black pen and duly signed by the parent/
guardian.
Recent
Passport Size
Photograph
PERSONAL DATA :
1).Full Name (with Surname) .
2). Residential Address
..
3).Pin: CityState............................
(Mobile) Home Tel:......................................
4)..Email
5). Date of Birth
6). Emergency Phone Number (Parent/Guardian/Local Guardian):.
7). Coaching Institute: ..Course: ..............Batch: ...
School Enrolled (Kota): Class: ..
I declare that the information given above is true to the best of my knowledge. I agree that if any information furnished
above found incorrect my admission is liable to be cancelled.
Date:
Purvanchal Hostel
Signature of the Parents/Guardian
.
Signature of the student
..
FAMI LY BACKGROUND :
1) Full name of the Parent/Guardian ..
2) Relationship
3) Occupation ..
Designation
4) Permanent Address
Email: .Tel. No. (Mobile /Res.)
NEAREST LOCAL GUARDIAN (Kota or in Rajasthan)
5) Name and address of contact person who should be contacted (in case of emergency)
1) Name .
Address .........
Tel. No. (Mob / Res) .
2) Name .
Address ..
Tel. No. (Mob / Res) .
Date:
..
Signature of (Parents /Guardian)
..
(For Office Use Only)
(To be filled up by respective Hostel Warden)
Allotted Room No. ..
Please accept Rs.only) as Room Rent. /
Hostel Security and Mess Security, from Mr.
Room Rent Rs ..Securities Rs ....
WARDEN
Purvanchal Hostel
Signature of Director
Undertaking
I, the undersigned hereby solemnly affirm and declare that:
(I) I confirm that if I accept and allotted the hostel facility, I shall abide by the rule and regulation of Purvanchal Hostel.
Rules of the Hostel and all other documents or instructions( Given in Application form), as framed, and enforced from time to time in any form and
manner, whatever it may be (hereinafter jointly referred to as Rules & Regulations).
(ii) I agree that I shall not be entitled to claim my admission to the hostel as a matter of right.
(iii) I understand that the Hostel has the full authority for the inspection of the room, bags, almirahs or any of my personal belongings at any time
during day and/or night.
(iv) I understand and agree that entrance of outsiders in the hostel is restricted. Entry and/or stay of my parents and any other visitor in the Guest
House (if authorized) is subject to the permission of warden and other concerned authorities of the Institute and if the Institute may take any
disciplinary action against the persons so permitted, in case of any misconduct or any damage or loss caused to person or property
belonging to the Institute in any manner for breach of Rules & Regulations.
(v) I shall inform the hostel authorities and my parents instantly; and shall be liable to pay for any expenditure incurred by the hostel authorities on
my treatment for any illness or disease or personal injury or otherwise due to any reason during my stay in the hostel.
(vi) Hostel management or its any staff will not be held responsible, if the student takes any action which is against the Indian Law or the Life of the
student. In any adverse situation like anxiety, depression, neurosis (such as phobias, obsessions and so on), psychosis (a mental disorder where
you lose your contact with reality) stress or fatigue student wont take any step which is against his life.
(vii) I agree that I shall not paste any poster or painting on the walls of rooms or at other places in and outside hostel premises.
(viii) I understand and agree that if absent myself from the hostel without permission, I am liable for disciplinary action, which may also amount to
rustication/expulsion from the hostel.
(ix) If I am detained during the duration of the course due to misconduct or any other reason whatsoever, I shall vacate the hostel
immediately and the fee will not be refundable.
(x) I understand and agree that smoking is prohibited in the hostel buildings. Gambling in any form such as playing cards (even without money at
stake), consumption of alcohol, use of drugs and narcotics and even possession of such things are prohibited.
(xi) I shall be liable to pay for any damage caused by me to the hostel either alone or jointly with others and face disciplinary action.
(xii) I understand and agree that hostel fee will not be refunded in case of expulsion or rustication or in case I leave the hostel in between the
academic session.
(xiii) I agree that I shall not use the service of a hostel staff for personal work even on payment. I shall also not bring any service from outside even
temporarily.
(xiv) I shall not misuse electricity by using electrical gadgets like irons, heaters, audio players, convector, immersion rod, electric iron etc.
Signature of the Parent/legal Guardian (specify relation)
Purvanchal Hostel
Signature of Applicant.
Date:
Purvanchal Hostel
Date:
