Hostel Admission Form

VBS Purvanchal University Jaunpur
www.vbspu.ac.in
__________________________________________________________________________________
Hostel Admission Form
1. Name of the student: ________________________________________________ Please affix a

2. Department: ______________________________________________________ recent passport
size photograph
3. Course: ______________________________ Semester: ___________________
4. Session: __________________ Category: (UR/OBC/SC/ST): ________________
Do not staple
5. Department Roll No.: _____________University Enrollment No.: _____________
6. Father's/Guardian's Name: ___________________________________________
7. Father's/Guardian's Address:
House No.: ____________ Street: __________________________________________________________
Village: __________________________________ Post: ________________________________________
District: __________________State: _________ Pin: ______________ Phone/Mobile: _________________
8. Permanent Address:
House No.: ______________Street _________________________________________________________
Village: __________________________________ Post: ________________________________________
District: _________________ State: __________ Pin: ______________ Phone/Mobile: ________________
9. Address for Correspondence:
House No.: ___________ Street: ___________________________________________________________
District: __________________ State: _________ Pin: _____________ Phone/Mobile: _________________
10. Details of Last Examination Passed:
a. Examination: ___________________________ b. Year of Passing: _____________________________
c. Percentage of Marks Secured: _____________ d. Name of School/College: _______________________
______________________________________________________________________________________
11. Chronic Health Problem: _____________________________________ Blood Group: ________________
(Specify if any)
12. Allergic to: ____________________________________________________________________________
13. Proneness to Reaction of Medicine (Specify if any):____________________________________________
* Student is required to submit 2-Passport size photograph during admission.
Date: ______________________
Forwarded by
Head of the Department with seal Full Signature of the candidate
________________________________________________________________________________________
OFFICE USE
Allotment Details: Hostel: ___________________________________________ Room No: _______________
Signature of Warden with seal Signature of Chief Warden with seal

Detail of Local guardian:
Name of Local Guardian: _______________________________________________
Relation with Local Guardian: ____________________________________________
Please affix a
Address of Local Guardians: _____________________________________________ recent passport
size photograph of
____________________________________________________________________
local guardian
____________________________________________________________________
___________________________________ Phone/Mobile: _______________________ Do not staple
Signature of Local Guardian

Date:
Place:
Undertaking by the Student (Ragging)
I___________________________________________ s/o or d/o ____________________________________

shall not involve in ragging. If any complaint of ragging is registered against me by any victim then the
University and district administration will be free to take disciplinary action as per the directions of State
government, University Grants Commission and Supreme Court of India.
Date: Signature of the Student
Undertaking by the Student
I ___________________________________________ s/o or d/o ____________________________________

declare that I shall abide by the rules of the hostel. In case of any violation of rules or misconduct, I shall accept
the decision taken by the hostel authority or other appropriate authority against me.

Declaration by the Student
I ___________________________________________ s/o or d/o ____________________________________

declare that neither I have been punished for any criminal offence nor any criminal case is pending against me.
I also declare that the information given by me in this form is true and correct to the best of my knowledge and
belief.

Undertaking by Local Guardian
I___________________________________ local guardian of Mr. /Ms. _______________________________

take the responsibility of looking after her during any emergency or crisis arising out of any reason and shall
cooperate with the hostel authorities.
Date: Signature of Local Guardian

Declaration by Father/ Guardian
I __________________________________ Father/Guardian of _____________________________________

declare that my ward needs to take my permission before going anywhere other than my residence or his/ her
local guardian’s residence and in case of any picnic, tour organized by the department he/she may be allowed
on my permission/ permission of the local guardian. The hostel authority shall not be responsible for any
matter/activities of my ward outside the hostel premises. In case of any violation of rules or misconduct by my
ward, the decision of the hostel authority shall be acceptable to me.
Date:
Place: Signature of Father/Guardian
FEE DEATIL
S. Date Name of the Department Chief Mess A/c Total
No. Bank A/c Warden A/c
Total
Date:
Place: Full Signature of the Student
Signature of Warden with Seal

VBS Purvanchal University Jaunpur
www.vbspu.ac.in
______________________________________________________
Hostel Admission Form
(Computer Performa)
1. Name of the Student (In Block Letter) (Leave a space between two words)
Mobile Number of Student
2. Name of the Father
Mobile Number of Father/Guardian
3. Name of the Mother
4. Class
5. Year Semester
(Write: First/Second/Third/Fourth)(Write: I/II/III/IV/V/VI/VII/VIII)
4. Department
5. Address for Correspondence
6. Permanent Address
Signature of the Student

Hostel Admission Form

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VBS Purvanchal University Jaunpur

1. Name of the student: ________________________________________________ Please affix a

Signature of Warden with seal Signature of Chief Warden with seal

Signature of Local Guardian

I___________________________________________ s/o or d/o ____________________________________

Date: Signature of the Student

Undertaking by the Student

I ___________________________________________ s/o or d/o ____________________________________

Date: Signature of the Student

I ___________________________________________ s/o or d/o ____________________________________

Date: Signature of the Student

I___________________________________ local guardian of Mr. /Ms. _______________________________

Date: Signature of Local Guardian

I __________________________________ Father/Guardian of _____________________________________

Signature of Warden with Seal

Mobile Number of Student

2. Name of the Father

Mobile Number of Father/Guardian

3. Name of the Mother

5. Address for Correspondence

Signature of the Student

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