From:- Dated:-

Student`s Name:- ………………………………………………………………………………………………………………………….………………

Father`s Name:- …………………………………………………………………………………………………………………………..……………..
Mother’s Name:- …………………………………………………………………………………………………………………………………………..
Student`s Permanent Address:- …….……………………………………..……………………………………………………………………… .
………………………………………………………………………………………………………………………………………………………………..……
Student`s Present address:- 1. KALINGA BOYS HOSTEL ( √/× )

2. KALINGA GIRLS HOSTEL ( √/× )

MOBILE NO:-…………….………………………………………………………………………………………………………………….
EMAIL ID:- …………..…….………………………………………………………………………………………………………………..
Adhar card no. / ID No:- …………………………………………………………….………………………………..................
D.O.B:-…….…./…………/…………………..
University Enrollment No:- …………………………………………………………….……………………………………………..

To,

The Vice Chancellor,

Kalinga University,
Gram- Kotni,
Palod,Tec –Arang,
District-Raipur-492101,
Chhattisgarh

UNDERTAKING/AFFIDAVIT

Respected Sir/Mam,

I………………………………………………………………………….…….aged about ………….year , S/o / d/o ...………………… …………………………….

…………..R/o………………………………………………………………………….………. is a regular student of Kalinga University vide Enrollment
No.: ………….…………………………………../Roll No…………………………under the course………………………………….……………I hereby tender
the following undertaking with regard to my eligibility document/conduct as a statutory requirement for admission/award of
Mark Cards/Degree,in the aforesaid course.

a) That I have passed my matriculation/10th /High School Examination in the session of……………………………… bearing roll
no………………………..from the School/Institute ……………

Affiliated to ……………………………..board.

b) That I have passed my 12th /Sr. Secondary Examination in the session

 of……………………………… bearing roll no………………………..from the School/Institute …………… Affiliated to
……………………………..board.

c) That I will/have regularly attend(ed) the classes and will maintain /have maintained atleast 75% attendance in my
classes.

d) I appeared for my Bachelor /Masters (Please specify)………………………. Year/ Semester examination in the University
campus and passed the same, vide roll no …………….. ……….. in the year…………………………… .
e) That the eligibility documents submitted by me are true & genuine to the best of my knowledge and belief.
f) That during the course of study I will not / was not in any kind of regular job either in any Govt, Semi govt or private
authority/Company.
g) That during the course of the study I will not / was not doing any other regular course from any other university.

h) That I will not / was not indulged in any sort of legal cases, Whether Criminal/Civil during the course of study.

i) That I will not get / was not involved in any malpractice, misconduct, fraud in any manner during my tenure of study in
the University.
j) That my above statement is true & correct and in case any document ,information & statement given by me in this
affidavit are found false, fake, duplicate ,wrong and forged , the University will have every right to cancel /withdraw my
Mark Card/Degree issued by the University and University may take appropriate legal action in this regard against me.

Deponent

Verification :-

I above named deponent ,do hereby solemnly verify that the contents of my above affidavit are true &
correct within my knowledge & belief and nothing has been concealed .

Signed and verified at…………………………………… on this ………………………………day of year 20…………

Deponent
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