Sr. No.
: 26678 (for office use only)
GURU JAMBHESHWAR UNIVERSITY OF SCIENCE & TECHNOLOGY,
HISAR
(HOSTEL STAY FORM for session 2025-26 )
Date of Admission : 31-07-2025
Hostel : Boys Hostel 4
Name : Karan
Mobile No. (Self) : 7982402586
Email :
[email protected]Father`s Name & Mob. : Naresh kumar - 9891913842
Mother`s Name & Mob. : Brijesh - 9891914415
Department : Department of Printing Technology
Course : B.TECH. (PRINTING TECHNOLOGY)
Year :1
Registration No. : 2514411
Date of Birth : 15/11/2007
Category : BCA
Permanent Address : HNO.129 GALI NO. 4 NEAR HANUMAN MANDIR BALLABGARH FARIDABAD Haryana 121004, BA
Visitor`s Details : Naresh kumar - 9891913842 - Yadav colony ballabgarh faridabad
: Brijesh - 9891914415 - Yadav colony ballabgarh faridabad
Local Guardian`s Details : Bijender kumar - 9992069060 - Gju hisar
(In case details of local guardian is not provided by the resident, the Chairperson/Director of the concerned dept. will be considered as local
guardian for residents of Girls Hostel.)
Blood Group : O-
Aadhaar No. : 475594255984
Account Details
Account No : 670218210009216
IFSC Code : BKID0006702
Bank Name : Bank of india
Old Residence Details (if you are an old resident of the Hostel)
Hostel : ___________________________________________
Room No. : ___________________________________________
Session : ___________________________________________
Dues if any : ___________________________________________
Recommendation of Coordinator/Warden ......................................................................... Signature ..................................
I undertake to abide by all the hostel rules and regulations of the University failing which disciplinary action may be
taken against me. I will not keep iron rod/ weapon/ arms of any kind in the hostel. I will not keep and use heater/electric
iron/induction etc. Further, I will vacate the hostel any time as per requirement of the University. The undertakings and
consents about not involving in activities such as ragging, etc. are enclosed. I agreed to abide by the rules and regulations of
GJUS&T, Hisar in letter spirit. Further, No FIR against me in any criminal cases has been lodged till date.
Father/Guardian`s Signature Counter Signature (with seal) Director/Chairperson Signature of the Applicant
Date : .........
Note : Please submit Medical Fitness Certificate with this application form, if you are fresh student.
CERTIFICATE FROM THE CHAIRPERSON/HEAD OF
DEPARTMENT
It is recommended that Mr./Ms. Karan Son/Daughter of Sh. Naresh kumar is a bonafide student/research scholar/project
fellow of this Department and may be admitted to the University Hostel. I certify that the address of the applicant given
above is the same as given in the admission form of the Department and it is not located within 30 kms. (Applicable for
Girls) and 40 kms. (Applicable for Boys) radius of Hisar city. In case the applicant leaves the Department or his/her
name is struck off on account of non-payment of dues or other reason, I shall inform the Chief Warden. I shall not issue
the Roll No. of the Examination/provisional certificate/transcript of degree to the applicant unless he/she produces a NO
DUES CERTIFICATE from the Coordinator/Warden/Dy. Chief Warden/Chief Warden. His/Her position in the Entrance
Merit List is ________________________ . I shall also share the responsibility in case of any need by hostel
administration in any emergency regarding him/her.
Signature Chairperson
(Supervisor) (In case of Ph.D. Student) (with seal)
UNDERTAKING ABOUT RAGGING
I have read page 37 of the University prospectus (2025-26) regarding the direction and `Zero Tolerance` about ragging. I
pledge to abide by the directions and guidelines of Supreme Court, Government of India, UGC, State Government and
Guru Jambheshwar University of Science and Technology about ragging. If at any stage of my stay in the hostel I am
found involved in the incident of ragging I will accept appropriate punishment, fine or both from the university
authorities & be ready to face legal action.
Signature of the applicant with date
UNDERTAKING ABOUT NON-CONSUMPTION OF SMOKING,
ALCOHOL AND DRUGS
I pledge to abide by the directions and guidelines of Supreme Court, Government of India, State Government and Guru
Jambheshwar University of Science and Technology about abuse of drugs and alcohol in the University campus. If at
any stage of my stay in the University and hostels, I am found under the influence, possession or consumption of
Drugs/alcohol/smoking I will accept appropriate punishment, fine or both from the university authorities & be ready to
face legal action.
Signature of the applicant with date
UNDERTAKING FROM PARENTS ABOUT ALCOHOL AND DRUGS ABUSE
My son/daughter has no past record of indulgence in any type of drug abuse or consumption of alcohol. I fully take the
responsibility that he/she will continue to maintain non indulgence in drugs and alcohol throughout his/her stay in the
University and hostel. If at any stage of his/her stay in the University and hostels, he/she found under the influence,
possession or consumption of Drugs or alcohol I will accept appropriate punishment, fine or both imposed on my ward
by the university authorities.
Signature of the parents with date
Mother ..................................................
Father ...................................................
CERTIFICATE FROM THE CHAIRPERSON/HEAD OF DEPARTMENT
(For female employee only)
It is recommended that Ms. Karan D/W of Sh. Naresh kumar is working as ________________________ in this
department and may be allowed room in WWH. I certify that the address of the applicant is the same as given in her
application and it is not located withing 30 KM radius of Hisar city. In case the applicant leaves the department, I shall
inform the Chief Warden. I shall not clear her last payment/salary/benefit/issue experience certificate of the applicant
unless she produce a NO DUES CERTIFICATE from the Coordinator/Warden/Deputy Chief Warden/Chief Warden. I
shall also share the responsibility in case of need by Hostel Administration due to any emergency regarding her/him.
Chaiperson/Head of the Department with Seal
UNDERTAKING FROM PARENTS/SPOUSE
I ........................................... F/M/H of Mr./Ms ....................................................... is giving my consent to stay in the
hostel. My ward/spouse will abide by all the rules and regulations of the hostel. Further, I will share the responsibility of
my ward/spouse in case of any emergency as and when required.
Signature of Parents/Spouse
Date .............................
