THIS FORM WILL NOT BE ACCEPTED WITHOUT ANNEXURE-I &ANNEXURE-II DECLARATION FILLED BY THE STUDENT & PARENTS/GUARDIANS.

GURU NANAK DEV UNIVERSITY,AMRITSAR Hostel Admission form Session 2013-2014

Sr. no. Note : 1. Fill the form legibly. 2. Incomplete Form will be summarily rejected. 1. Name of the Applicant _________________________________ Affix photo of the 2. Nationality ___________________________________________ applicant attested by the Head of the dept. 3. Date of Birth ______________ Blood Group ______________ Attach an extra 4. Roll No. __________________ Class ____________________ attested copy of the Department _________________________________________ photo with the Regd. No. __________________________________________ Application form 5. a) Father's Name ___________________________________________________ b) Guardian's Name (If, Father is not there) ________________________________________________ c) Father's/Guardian's Address __________________________________________________________ __________________________________________________________________________________ d) Occupation ________________________________________________________________________ e) Telephone No. Residence (with STD Code) ______________________________________________ f) Father's/guardian's Annual Income ___________________________________________________ 6. a) Local guardian's Name & Address (Who can be called at time of emergency) ____________________ __________________________________________________________________________________ ____________________________________________________________________________________ b) Phone No. Resi. ________________Office _____________ Mobile ___________________ 7. Will you keep your Motorbike/Scooter etc. in the Hostel during your stay in the Hostel ? If, yes write the Registration No. of the vehicle ______________ hostel residents are strictly prohibited from keeping cars, Royal Enfield Motor Cycle or other bikes of 300 cc or more engine capacity in the Hostel. 8. Do you belong to Schedule Caste/Tribe : Yes/No_____________ 9. Are You suffering from some chronic Disease ? If Yes, name of the disease : ___________ 10. Have you resided in the Hostel before ? If yes, mention the details: Roll no. ____________ Room no. ______________ Block _______________ Session ____________ 11. Have you ever been punished for Misconduct/Violating the Hostel Rules/Indiscipline etc. If yes give detail _______________________________________________________________________________ 12. a) Merit Position in Entrance Test : ( For Fresher) _____________________________________________ b) CGPA/ % Marks obtained in Previous Session ______________________________________________ DECLARATION I_________________________ (Name) have read the rules of the Hostel and have noted and understood that these rule will strictly apply on my admission and stay in the Hostel and shall follow them accordingly. I shall pay the Hostel dues from time to time, as required.

Dated_____________

Signature of the Applicant

I. recommend that ________________ Class ____________ be admitted to the University Hostel. He/She has paid the Departmental fees vide Receipt No. ________ dated _________. He/She has been issued Hostel Card No. _______ . the Department takes the responsibility of his/her good conduct and payment of dues/expenses of the Hostel. He/She will be issued the Examination roll No. on production of "No Due Slip" from the Hostel office.

Dated_____________

Head of the Department

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UNDERTAKING AND CERTIFICATE FROM THE APPLICANT Certify that all the entries made in the Application Form are correct to the best of my knowledge. I agree to obey all the Hostel Rules and provisions which the University Authorities shall make from time to time for my studies and betterment. I shall not take part in any activities which are against the University administration. I properly understand that University authorities can take disciplinary action against me for any illegal act and for violating the Hostel Rules. I solemnly declare that I have not been punished or declared incompetent by any Board/University. I have thoroughly gone through the warnings/punishments/rules regarding Ragging which have been mention in the Hostel Prospectus. I undertake and promises that I shall not take part in any activity related to Ragging.

Dated__________ Full Signature of the Student __________________________________________________________________________________________ ONLY FOR RESIDENTS OF MATA NANAKI GIRLS HOSTEL Detail of the Persons eligible to meet the Hostel Residents: 1. No body except close relatives can meet the Hostel Resident. 2. Only five guests as mentioned below can meet the Hostel Resident. __________________________________________________________________________________________ Sr. No. Name Relation Full Address __________________________________________________________________________________________ 1. 2. 3. 4. 5. __________________________________________________________________________________________ Should the Student be allowed to visit her Home/Market/Cinema or outing/excursion etc? Yes/No_____ Alone, with companions or in a Group ____________________________________________________ I assure that my son/daughter will follow the Hostel rules and will pay all the Hostel dues. I shall be responsible for his/her every kind of conduct inside/outside the Hostel as well as University limit. My son/daughter will not associate himself/herself with any kind of Ragging activity directly or indirectly. Dated_______________ Signature of Father/Guardian - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -- -- - - - - - - - - - - - - - - - - - - - - - - FOR OFFICE USE Room No. ____________________ Block____________________________________________________ Hostel Roll No. ___________________Receipt No. ___________________ Dated____________________ Motor Cycle/Two Wheeler No. ______________________________________________________________

Warden Dean Students' Welfare - - - - - - - - - - - - - - - - - -- - - - - -- - - -- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -- - - - - - - - FOR OFFICE USE Received Hostel Rent Rs. ___________________ vide Receipt No. ________________Dated ____________ Received Mess Security Rs _________________ vide Receipt No. ________________ Dated ___________

Signatures of Hostel Clerk

Note: At the time of hostel admission Rs. 100 will be charged extra for Hostel admission form (to be paid in the respective Hostel office) .

Annexure-I
Self Declaration by the Student
I, _________________________________________________________________________________________________ (full name of student with admission/registration/enrolment number) S/o/D/o of Shri ______________________ , having been admitted to ________________________________________ (name of the institution), have received a copy of the UGC Regulation on Curbing the Menace of Ragging in Higher Educational Institutions, 2009, (hereinafter called the "Regulations") carefully read and fully understood the provisions contained in the said Regulations. 2. I have, in particular, perused clause 3 of the Regulations and am aware as to what constitutes ragging. 3. I have also, in particular, perused clause 7 and clause 9.1 of the Regulations and am fully aware of the penal and administrative action that is liable to be taken against me in case I am found guilty of or abetting ragging, actively or passively, or being part of a conspiracy to promote ragging. 4. I hereby solemnly aver and undertake that a) I will not indulge in any behaviour or act that may be constituted as ragging under clause 3 of the Regulations. b) I will not participate in or abet or propagate through any act of commission or omission that may be constituted as ragging under the clause 3 of the Regulations. 5. I hereby affirm that, if found guilty of ragging, I am liable for punishment according to clause 9.1 of the Regulations, without prejudice to any other criminal action that may be taken against me under any penal law or any law for the time being in force. 6. I hereby declare that I have not been expelled or debarred from admission in any institution in the country on account of found being guilty of, abetting of being part of a conspiracy to promote ragging; and further affirm that of in case the declaration is found to be untrue, I am aware that my admission is liable to be cancelled. Declared this _____________ day of _________ month of _______ year _____.

Signature of Student Name :_______________________ Address :______________________ Telephone/Mobile No. :__________ SELF DECLARATION Verified that the contents of this self declaration are true to the best of my knowledge and no part of the self declaration is false and nothing has been concealed of misstated therein. Verified at ________ of this the ________(day) of _________(month), _______(Year) _____________________

Signature of Student

Annexure-II
1. Self Declaration by Parent/Guardian Mr./Mrs../Ms.___________________________(full name of parent/guardian) father/mother/guardian of _____________________(full name of student with admission/registration/enrolment number), having been admitted to (name of the institution)_____________________, have received a copy of the UGC Regulations of Curbing the Menace of Ragging in Higher Educational Institutions, 2009, (hereinafter called the "Regulations"), carefully read and fully understood the provisions contained in the said Regulations. I have, in particular, perused clause 3 of the Regulations and am aware as to what constitutes ragging. I have also, in particular, perused clause 7 and clause 9.1 of the Regulations and am fully aware of the penal and administrative action that is liable to be taken against my ward in case he/she is found guilty of or abetting ragging, actively or passively, or being part of a conspiracy to promote ragging. I hereby solemnly aver and undertake that (a) My ward will not indulge in any behavior or act that may be constituted as ragging under clause 3 of the Regulations. (b) My ward will not participate in or abet or propagate through any act of commission or omission that may be constituted as ragging under clause 3 of the Regulations. I hereby affirm that, if found guilty of ragging, my ward is liable for punishment according to clause 9.1 of the Regulations, without prejudice to any other criminal action that may be taken against my ward under any penal law or any law for the time being in force. I hereby declare that my ward has not been expelled of debarred from admission in any institution in the country on account of being found guilty of, abetting or being part of a conspiracy to promote, ragging; and further affirm that. In case the declaration is found to be untrue the admission of my ward is liable to be cancelled. Declared this________day of__________month of_______year. Signature of Father/Mother Name :________________________ Address :_______________________ Telephone/Mobile No. :_____________ Self Declaration by Parent/Guardian Verified that the contents of this self declaration are true to the best of my knowledge and no part of the self declaration is false and nothing has been concealed or misstated therein. Verified as (Place)__________ of this the (day)_______ of (month)____, (Year)_____

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Signature of Father/Mother/Guardian