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Guru Jambheshwar University of Science & Technology, Hisar (HOSTEL STAY FORM For Session 2023-24)

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Meenu Narwal
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96 views5 pages

Guru Jambheshwar University of Science & Technology, Hisar (HOSTEL STAY FORM For Session 2023-24)

Uploaded by

Meenu Narwal
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Sr. No.

: 13752

GURU JAMBHESHWAR UNIVERSITY OF SCIENCE & TECHNOLOGY,


HISAR
(HOSTEL STAY FORM for session 2023-24 )

Hostel : Girls Hostel 2


Name : MEENU
Mobile No. (Self) : 9350161064
Email : [email protected]
Father`s Name : SUBHASH
Father`s Mobile No. : 9416655030
Mother`s Name : JYOTI
Department : GJUST - Department of Computer Science and Engineering
Course : B.TECH. (COMPUTER SCIENCE & ENGINEERING)
Year :4
Registration No. : 200010130067
Date of Birth : 05/08/2002
Category :
Permanent Address : VPO kherinaru, karnal Karnal Karnal Karnal Haryana 132036, Karnal, Haryana
Visitor`s Details : Tarun - 9518032287 - VPO kherinaru, Karnal
: Subhash - 9416655030 - VPO kherinaru, Karnal
Blood Group : O+
Aadhaar No. : nill

Account Details
Account No : 30030657296
IFSC Code : SBIN0016255
Bank Name : SBI

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 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.

Father/Guardian`s Signature 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. MEENU Son/Daughter of Sh. SUBHASH 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. 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.
Date : Chairperson

(with seal)

UNDERTAKING ABOUT RAGGING


I have read clause 7 page 11 of the University prospectus (2023-24) 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)

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 ...................................................
UNDERTAKING FROM PARENTS/HUSBAND

I ........................................... F/M/H of Mr./Ms ....................................................... is giving my consent to stay in the


hostel. Further, I will share the responsibility of my ward/spouse in case of any emergency as and when required.

Signature of Parents/Husband

Date .............................

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