Hostel Name:
Motilal Nehru National Institute of technology, Allahabad- 211002
Hostel admission form (20 - 20 )
(To be filled by office)
Room No. Allotted:
Mess No. Allotted:
Mess fee details: Bank: Draft No.: Date: Photograph
Signature of Signature of Signature of
Accountant Care Taker Warden Incharge/Warden
(To be filled by the Applicant)
1. Name of the Candidate …………………………………………………………………………..
(in Capital letters as per Institute record)
2. Registration No…………………………………………………………………………………..
3. Class and Branch ………………………………………………………………………………..
4. Date and Place of Birth ………………………………………………………………………….
5. Belonging State and Domicile State …………………………………………..
6. Year of Joining the Institute …………………………………………………………………….
7. Country and Nationality ………………………………………………………………………..
8. Name and Address of Parent/Guardian …………………………………………………………
…………………………………………………………………………………………………..
9. Permanent Address for Correspondence ……………………………………………………….
………………………………………………………………………………………………….
10. Name, Address and Telephone No. of nearest Local Guardian ………………………………
………………………………………………………………………………………………….
11. Name and Address of any Senior Student of
the Institute known to you ..........................................................................................................
12. Father/Guardian contact (O) (R) (M)
Telephone with Code and
E-mail ID (E-mail)
13. Railway Station Nearest to Place of Residence ..........................................................................
14. Name of the Hostel of Last Year and Room No. ........................................................................
15. Category .................................................................. SC/ST/ OBC/Minority/General
16. Details of any disciplinary action taken in your last stay in Institute: (Yes/No)
(If yes): Year Semester Punishment Fine
It is to certify that all the entries made by me are correct and as per record. I assure you that I
will abide by the hotel rules and never indulge in any act of indiscipline. Further I will not involve
myself in any kind of ragging of activities. If found involved in ragging, I may be expelled from the
hostel and Institute.
Signature of the Student
UNDERTAKING
I ……………………………………………….. S/o ………………………………………….
give an undertaking that no damage would be caused to electrical fittings or furniture by me or any
of my visitors /guests. In default I would pay the present actual cost of the article and the fine as
deemed reasonable by the hostel administration.
I understand that room allotment is final and interchange of room without the permission of
CHIEF WARDEN is an offence. I default I am liable to be asked for disciplinary action including
vacation of hostel for one year/forever and /or a fine Rs.2000/-.
Signature of the Student
DETAILS OF INVENTORY ISSUED TO THE STUDENT
I have received the following furniture and fixture in my room from the Care Taker. I shall
be responsible for any loss and I will handover these items before leaving the hostel room.
Sl.No. Qty. Item Yes or No Sl. No. Qty. Item Yes of No
1. One Study Table Wooden/ 2. One Tea Table
Sunmica
3. One Chair Wooden/ S-Type/ 4. One Takhat/Newar Cot
Steel
5. One Ceiling Fan (Polar/ Khaitan/ 6. One Regulator (Polar/Khaitan/
Orient/Usha) Orient/Usha)
Date : Full Signature of the Student
(FOR OFFICE USE)
(i) The Student has returned all the Inventory issued to him at the time of leaving the hostel.
(ii) The Student has not returned the complete inventory issued to him and the details of
unreturned items are given below.
1. 2. 3.
4. 5. 6.
Care Taker Warden Incharge/ Warden
