MqulanaAzad

NATIONAL INSTITUTE OF TECHNOLOGY

e Passpor

BHOPAL. 462 05I (M.P)

Size

Photograph
r

1.

Name (In Capital Lemer)

'N2. Sch. No.

Class

BIood Group

Branch

Mobile No.

Email I.D.

*3.
4.
*5.

CATEGORY

State of Domocile

S.C./ST/OBC/GEN/PH

Mother Tonsue

Mother's Name

Father's Name

Occupati

Designation & Organisation

Address

Phone with STD Code No.

Name

6.

Mobile No.

& Address of Local Guardian

Phone No.

Mobile No.

7.

Deatils of any disciplinary action taken by the lnstitute

8.

Result of Previous Seurester

Semester

Result

/ Hostel Ar"rthority:

Max. Marks

Vo

of Marks / CGPA

il
ru
IV
V

VI

VII

vIII
9. For Ist year Students
ff
10. Undertaking:- I undertake

All India Rank

that I will abide by the rules &

't Information must be given

regulations of the Institute and will not

indulge in ragging or any action co-nnected with raggingl failing which I may be punished to the
extent of expulsion from the hostel / Institute.
,

r:.i

Signature of Student

No Dues for student residing in hostel in previous semester

Name

Room No.

was residing in Hostel No.

He/She has no mess dues and has handed over room to caretaker on

Signature of Mess Supervisor

Warden/Sr. Warden

Caretaker

Hostel Allotment Details

Bv DD No./Challan No.

Paid mess advance Rs.

Brutnch

Name of Ban

dated

'Alloted Hostel No.

Room No.

Signature of Mess Supervisor

Warden/Sr. Warden

Caretaker

Chairman, COW

Chairman COW Office

DECLARATION UNDERTAKING BY THE PARENT

1.

2.
a
J.

4.
5.

I hereby undertake to ensure that

with regard
My ward shall abide by the rules and legurlations plescribed in the prospectuts and other notif icittion.
rltles. project
to fulfilling requirements, In respect of minimLrm attenclence. CIass room assignnlcnts, exanlinaticln
assignment and study visit which arc e ssenti:rl parts of'the collrse stl'LlctLll'e.
bc
My ward shall mainiain good be haviour and discipline within the classroom, hostcl ancl catrtpus. He shall
open to the disciplinary action tbr violation of any of the rules prescribed thelein.

My ward shall not damage / deface or spoil the hostel room (including the finishing in the rooms) and

the

furniture and equipment provided by the authorities.

conlputer
My ward shall be responsible tol payrnent of clamage that may be caused to library books, eclLripnlcrlts,
laboratory etc through negl i gence.
I declare that in case of my ward disobe ys institr-rte lule s he will be liable fbr punishnlent ol.sltspcnsion or
punishment awarded to my
cancellation of admission as deeemed fit by the competent authority I shall accept the
ward by the institute authorities.
awitre thitt
I undertake that my ward will not involve in ragging or any activity connected with ragging. I am
for pungivcn
di|ections
also
ragging is cognizable offence. Hon'ble Surpremet Court and the Government has
ishment against ragging.
I shall accept
I further declare t[at if my ward is found to be involved in any act of indiscipline,

my u'ard.
the punishment/Disciplinary action taken by the institute authorities against

Signature of Parent / Guardian

Name:
Address:
Telephone with Code No.

Mob. No.
Place