JADAVPUR UNIVERSITY
KOLKATA-70003
Form No………………………………
Class (UG/PG/R.S./M.Phil): ………..
Sex (Male/Female): ………..………...
Section (Day/Evening): ……………...
University Hostel Boardership Application Form
(This application does not guarantee allotment)
Name: ………...………………………. ……………………………. …..…………………………………….
(BLOCK LETTER) (First Name) (Middle Name) (Surname)
Department……………………… Course: …………….. Year (I/ II/ III/ IV):………. Roll No.………………
Address: Village/Street (with Premises No.) ……………………………………………………………………
(Attach Proper Document)*
P.O.………………………….……..PIN……………………………P.S (must be mentioned):………………..
District………………………………..… Phone No.……………………..Mobile…………………………….
Nationality…………………………..…. Married/Unmarried…………………………. Blood group…………
Name of the Institution last attended and attach character certificate if not from Jadavpur University:.......................
…………………………………………………………………………………………………………………………
Father’s Name……………………………………………………….. Occupation………………………………
Monthly Income Rs…………………Phone No…………………… Signature………………………………….
(Attach Proper Document)**
Mother’s Name……………………………………………………….Occupation………………………………
Monthly Income………………………Phone No……………………..Signature……………………………….
(Attach Proper Document)**
Name & Address of Guardian/Local Guardian with phone No…………………………………………………..
Whether belongs to : SC/ST/OBC -A/OBC-B/PH
{If applicable put a Tick (√) & attach appropriate document}
Whether represented J.U. for Inter University Competition or admitted in Sports Quota: Yes/No.
(attach document)
Amount of Fellowship for R.S. /P.G. Scholarship: Rs…………………………………………………………..
I do hereby affirm that the information submitted by me are true to the best of my knowledge and I do hereby
undertake that I shall not participate in, abate, or propagate ragging in the hostel premises.*** I assure you that I
will follow and abide by the rules set in for hostel from time to time. University may take any action against me as
per rule if I violate any above-stated rule/s.
………………………………………… ….…… ………………………..……………………………
Signature of the Candidate with date Authenticated Signature of the Guardian with date
* Attested copy of AADHAAR CARD/ Voter Identity Card (EPIC)/Residential certificate issued by Gazetted Officer/
Employer.
** Income certificate from the employer (with office seal) for the employed person and for others from the Gazetted
Officer / B.D.O / S.D.O. and other similar higher official. Submission of attested copy of Income-Tax Return may
also be accepted as proof of Income.
*** Students selected for hostel admission have to submit on-line Anti-Ragging Affidavits (through web
portal: www.antiragging.in/ www.amanmovement.org) by candidate at the time of admission (Hostel) at Dean
of Students office.
Received a hostel-boarder ship Application Form No. …………. from Sri/Smt …………………………………… ..
…….……… of UG / PG / M.Phil / R.S under …………………………………………….……. department
Date:……………….. …………………………………………...
Signature of Dealing Asstt. (D.O.S.Office)
