TEZPUR UNIVERSITY
NAPAAM, TEZPUR – 784028, ASSAM
Application for Hostel Accommodation
For office use only Paste one recent
Roll No : passport size
Hostel allotted/Not allotted photograph
______________________________
Name of the Hostel
(If allotted)
Dean, Students Welfare
1 Name in full (Block Letters)
2. (a) Programme applied for
(b) Department
3. Father’s / Husband’s Name & Address Name…………………………………………………………………………….
Vill/Town/City/Street. ………………………………………………………
P.O. …………………………………………Pin
Phone No: (with STD code)
4. Guardian’s Name & Address
(if different from the address given in sl.
no. 3)
Name…………………………………………………………………………….
Vill/Town/City/Street. ………………………………………………………
P.O. …………………………………………Pin
Phone No: (with STD code)
5. Local Guardian’s Name & Address Name…………………………………………………………………………….
Vill/Town/City/Street. ………………………………………………………
P.O. …………………………………………Pin
Phone No: (with STD code)
6. Permanent Address Name…………………………………………………………………………….
Vill/Town/City/Street. ………………………………………………………
P.O. …………………………………………Pin
Phone No: (with STD code)
7. Correspondence Address
(if different from the address given in sl.
no. 6)
Name…………………………………………………………………………….
Vill/Town/City/Street. ………………………………………………………
P.O. …………………………………………Pin
Phone No: (with STD code)
8. State of domicile
9. Sex (√)
10. Category (√)
a)
b) Full Time Sponsored Part Time Project
11. Declaration:
I declare that if admitted to hostel, I shall abide by the Statutes, Ordinances, Rules and Regulations, Orders etc. of the University and of the Hostel that will be in force from time to time. I will submit myself to the disciplinary jurisdiction of the Vice Chancellor and other authorities of the University and the Hostel who may be vested with such powers under the Act, Ordinances and the Rules that have been framed there under by the University. I also declare that for any violation of the above, my admission into the Hostel and University shall be liable to be cancelled and I shall be liable to such other disciplinary action as may be decided by the University authorities.
Further, I declare an oath that the information given above is true and complete to the best of my knowledge and belief.
..……………………………….
Date: Full signature of the students
_________________________________________________________________________________________________________
12. Declaration of the Local Guardian:
I agree to be the local guardian of the above named student and I shall look after his/her conduct and take
care of his/her immediate needs, if any, during his/her stay in the hostel.
…....……………………………….
Date: Signature of the Local Guardian
_________________________________________________________________________________________________________
13. Declaration of the Guardian:
I undertake the responsibility of paying all dues of my son/daughter/wife regularly and for his/her due
compliance with all rules and regulations that are in force from time to time in the University Hostels.
The above named person (in Sl No. 5) will be the Local Guardian of my son/daughter/wife who shall take
first hand care of his/her conduct and take care of his/her needs during his/her stay in the Hostel.
…....……………………………….
Date: Signature of the Guardian
_________________________________________________________________________________________________________
FOR WARDEN’S USE
Seat allotted in the Room No ……………………………………………………………………………………………………….
Date:…………………….………………………………
Signature of the Warden
Male Female
Gen SC ST PWD OBC