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Hostel Form

This document is an application form for hostel admission at the National Institute of Technology Raipur for the session 2024-2025. It includes personal details of the student, Mudit Narayan Sahu, such as academic information, parental details, and medical background. The form requires signatures from both the student and parent, along with necessary enclosures, and emphasizes adherence to hostel rules.

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4 views

Hostel Form

This document is an application form for hostel admission at the National Institute of Technology Raipur for the session 2024-2025. It includes personal details of the student, Mudit Narayan Sahu, such as academic information, parental details, and medical background. The form requires signatures from both the student and parent, along with necessary enclosures, and emphasizes adherence to hostel rules.

Uploaded by

a3796323
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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National Institute of Technology Raipur

G.E. Road, Raipur Chhattisgarh - 492010, India


771-2254200, www.nitrr.ac.in

App. No. :5610


Application form for Hostel Admission Session 2024-2025
(To be filled by student in CAPITAL LETTERS, Incomplete forms will not be accepted)

Student’s Name : MUDITYA NARAYAN SAHU Category : OBC Paste recent


passport size
Student’s ID No : Roll No : 21118059 Enrollment No : 210683 Colour Photograph
(Self attested)
Current Semester : VI Branch : ITY Year of entry in the institute : 2021-2022
(Please attach one
Apply Semester : VII Blood Group : O+ve Date of Birth : 13-Oct-2001 additional passport
size photograph)
Gender : MALE Apply Date : 23/03/2024

Alloted Category : OBC Physically Handicapped : NO

Medical Background (Any serious Illness) :-

Email ID : [email protected] Mobile No : 8236018682

Bank Account Number : 35143610822 State Bank of India, Branch : COLLECTORATE BRANCH,RUDRI

Father’s Name : RAJESH SAHU


Paste recent
passport size
Occupation with Designation(Father) :
Colour
Photograph of the
Mother’s Name : SULOCHANA
Father
Occupation with Designation(Mother) :

Paste recent
Present Postal Address of Parent : NEAR LAXMI NIWASH, GOKULPUR WARD DHAMTARI, passport size
DHAMTARI, NA, CHHATTISGARH, 493773 Colour
Photograph of the
Mother
City : DHAMTARI State : CHHATTISGARH Pin Code : 493773

Email-ID : Mobile No : Phone :0

Local Guardian’s Name (At The Two Most Only) :


Paste recent
passport size
Guardian’s Address : NEAR LAXMI NIWAS CHOWK, GOKULPUR WARD,
Colour
DHAMTARI,CHHATTISGARH,493773
Photograph of the
Local Guardian
Email-ID : -----------------------
Signature
STD Code : Mobile No : 7970247906 Phone :

Details of Earlier Hostel Admission RESULTS


Years Academic Hostel Room No. CGPA SGPA Status Name of the Subjects
Sem
Year (Pass / Fail) (if not cleared)

1st Year 1st

2nd
2nd Year
3rd
3rd Year
4th

4th Year 5th

6th

7th

8th
DECLARATION BY THE STUDENT

I have read the hostel rules and I do agree to abide by these rules as well as such other rules, which are

framed by the institute from time to time. I also undertake to pay the hostel dues in time. I hereby solemnly and

sincerely affirm that the statements made and the information furnished above is true to the best of my

knowledge & belief. If any of the information furnished therein found to be incorrect of false, I understand that I

Date :
Place : Signature of the Student

Enclosures:

1. OBC / ST / SC / PH Category Certificates.

1. Attested/Self Attested copy of Previous Semester's Mark Sheet.

3. Copy of Aadhar Card/Any address Proof.

UNDERTAKING

We have read all the instruction and hostel rules & regulations and undertake to abide by them.

Signature of the Parent Signature of the Student


Name : Name : MUDITYA NARAYAN SAHU
Date : Date :

Note: Without duly signed undertaking, students will not permit to register for next semester.

Hostel Admission No………………….

FOR OFFICE USE

Certified that he / she has paid in full the previous dues, if any, and hostel charges for the current

year viz. Rent, Water, Electric Charges, etc. and Mess Advance for current semester.

Amount Admitted to Hostel Room No


Receipt No.
Paid

Amount
Receipt No.
Paid

Hostel Accountant Warden Chief Warden


Date : Date : Date :

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