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VISVESVARAYA NATIONAL INSTITUTE OF TECHNOLOGY, NAGPUR 440 010Application form for Hostel Admission Session 2012-13

FOR OFFICE USE

Recp. No. C4/B/12/Amount

PaidAdmitted to

HB No.Room No.

Recp. No. C4/B/12/Amount

Paid

Date :

Students ID No Roll No.

(To be filled by the student in CAPITAL LETTERS, Incomplete Forms wil l not be accepted)

AIEEE (All IndiaRank)

Class B.Tech / B.Arch. Sem. I Branch

Yr. of entry in the Inst. 2 0 1 2 Enroll. No.

First Name

Fathers Name

Surname

Sex M / F Married Y / N Blood Group Date of Birth / /

D D M M Y Y Y Y

Account No. SBI, VRCE, Nagpur

E-mail : ______________________________________________________________________________

Mobile No. : __________________________________________________________________________

Fathers Full Name

STD Code

Phone 1

Phone 2

CompleteResidential

Address

Mobile 1

City Mobile 2

District PIN Code

State Country

E-mail : ________________________________________________ Income of Father : Rs. ________________ (p.a.)

Signature of student

Paste recentpassport

size ColourPhotograph

(DO NOTSTAPLE)

UG

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Students ID No

STD Code

Phone 1

Phone 2

Fathers Office /Business Addresswith Designation

Fax

City

District PIN Code

State Country

Phone 1

Phone 2

Name of LocalGuardian &Address at Nagpur

PIN Code

For Foreign Students

Country of Domicile

Passport No.

D E C L A R A T I O N B Y T H E S T U D E N T

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 college from time to time. I will not involve in any activities related to ragging or indiscipline. I also

undertake to pay the hostel dues in time. I hereby solemnly and sincerely affirm that 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 or false, I undersigned will be responsible for any consequences arising out of incorrect or false

information furnished in the application.

Date : Signature of studentPlace : Nagpur

Signature of Parent

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VISVESVARAYA NATIONAL INSTITUTE OF TECHNOLOGY, NAGPUR

U N D E R T A K I N G (I)

Students ID No

I understand that:

1. The students residing in the hostel are not allowed to keep and use motorized vehicles in the hostel. Defaulters

shall be fined and / removed from the hostel.

2. Consumption and possession of all types of alcohol, cigarettes, narcotics and other drugs would automatically

debar the student from residing in the Institute campus.

3. It is required to maintain the decorum in the hostel premises.

4. Hostel Management reserves the right to allow or not to allow stay of any student in the hostel.

I shall abide by all the rules and regulations prescribed by the Institute and amended from time to time andcooperate. I shall vacate the hostel room within four days from the last date of examination at the end of even term.

Signature of Parent / Guardian

Name : ____________________________________

Contact no. : ________________________________

Signature of Student

Name : ____________________________________

Date :

U N D E R T A K I N G (II)

I, . student of semester B.Tech./ B.Arch., RollNo do hereby solemnly affirm and undertake that I shall not indulge in any form of Ragging and that shallmake determine efforts to eradicate ragging totally.

I am fully aware that ragging of junior or other fellow students through physical or mental harassment is aheinous social evil and cognizable offence, that the barbarous act of ragging may disturb the mental balance of thestudents besides causing physical harm, that this may result into damaging consequence and adversely affect hiscareer permanently and that serious cognizance shall be taken if I am found involved in ragging or of any complaint in

this regard which may lead to my rustication from this Institute and also lodging a complaint with the police for takingaction against me under the prevailing rules. I am also aware that the use of motorized vehicles is prohibited on theVNIT Campus by hostellers.

Further, I undertake to follow the hostel rules as well as the directives given by hostel administration and Ishall be liable for disciplinary action, including expulsion from hostel, if I am found violating the same.

In the event of my in-eligibility to continue in the class for which I have registered, I shall vacate the Hostelimmediately.

Date : Signature of the student Place : Nagpur