भारतीय सूचना प्रोद्योगिकी संस्थान, नािपुर
Indian Institute of Information Technology, Nagpur
BSNL RTTC, near TV tower, beside Balaji Temple, Seminary Hills, Nagpur-440006.
Website: www.iiitn.ac.in.
Application form for Hostel Admission
Academic Session 2016-17
FOR OFFICE USE
Recp. No
st
(1 Sem)
Recp. No.
nd
(2 Sem)
Amount
Paid
Amount
Paid
C4/B/15/
C4/B/15/
Admitted to
Hostel.
Room No.
Date :
Students ID No
Roll No.
(To be filled by the student in CAPITAL LETTERS, Incomplete Forms will not be accepted)
JEE (All India
Rank)
Class
Sem.
B.Tech
Year of entry in the Inst.
I
Branch
Paste recent
passport
size Colour
Photograph
2 0 1 6 Enroll. No.
First Name
(DO NOT
STAPLE)
Mother’ Name
Father’s Name
Surname
Sex
M /F
Married
Y /N
Blood Group
Date of
Birth
/
D
D
M
/
M
Y
Y
Y
Y
E-mail : ______________________________________________________________________________
Mobile No. : ____________________
Emergency Contact No.:_______________________________
Fathers Full
Name
Complete
Residential
Address
STD Code
Phone 1
Phone 2
Mobile 1
City
Mobile 2
District
PIN Code
State
Country
E-mail of father : ___________________________________________________________________________
Income of Father : Rs. ________________ (Per Annum)
Signature of Student
भारतीय सूचना प्रोद्योगिकी संस्थान, नािपुर
Indian Institute of Information Technology, Nagpur, Camp
Office:1st Floor Old Library Building VNIT South Ambazari Road Nagpur-4400. Website: www.iiitn.ac.in.
भारतीय सूचना प्रोद्योगिकी संस्थान, नािपुर
Indian Institute of Information Technology, Nagpur
BSNL RTTC, near TV tower, beside Balaji Temple, Seminary Hills, Nagpur-440006.
Website: www.iiitn.ac.in.
Students ID No
Father’s Office /
Business Address
with Designation
STD Code
Phone 1
Phone 2
Fax
City
District
PIN Code
State
Country
Name of Guardian
& Address
Phone 1
Phone 2
PIN Code
Name and Contact number of two relatives
1)
Mobile No.
2)
Mobile No.
D E C L A R A T I O N
B Y
T H E
S T U D E N T
I have read the hostel rules and I do agree to abide by these rules as well as such other rules which are
framed by the Institute from time to time. I will not involve in any activities related to ragging or indiscipline. I also
undertake to pay the hostel dues in time. I hereby solemnly and sincerely affirm that the statements made and
the information furnished above is true to the best of my knowledge & belief. If any of the information furnished
therein found to be incorrect or false, I undersigned will be responsible for any consequences arising out of
incorrect or false information furnished in the application.
Date
Place
:
: Nagpur
Signature of Student
Signature of Parent
भारतीय सूचना प्रोद्योगिकी संस्थान, नािपुर
Indian Institute of Information Technology, Nagpur, Camp
Office:1st Floor Old Library Building VNIT South Ambazari Road Nagpur-4400. Website: www.iiitn.ac.in.
भारतीय सूचना प्रोद्योगिकी संस्थान, नािपुर
Indian Institute of Information Technology, Nagpur
BSNL RTTC, near TV tower, beside Balaji Temple, Seminary Hills, Nagpur-440006.
Website: www.iiitn.ac.in.
UNDERTAKING
( H o s t e l )
Student ID No
I understand that:
1. The students residing in the hostel are not allowed to keep and use motorized vehicles in the hostel.
Defaulters shall be Defaulters shall be removed from the hostel.
2. Consumption and possession of all types of alcohol, cigarettes, narcotics and other drugs would
automatically debar the student from residing in the Institute campus.
3. It is required to maintain the decorum in the hostel premises. Misbehavior with fellow students Institute
staff / hostel staff / warden will lead to rustication from hostel.
4. Hostel Management reserves the right to allow or not to allow stay of any student in the hostel.
I shall abide by all the rules and regulations prescribed by the Institute and amended from time to time
and cooperate. I shall vacate the hostel room within four days from the last date of examination at the end of
even term.
Signature of Parent / Guardian
Signature of Student
Name : ____________________________
Name : : ____________________________
Contact no. : ________________________________
__________________________________
Date :
भारतीय सूचना प्रोद्योगिकी संस्थान, नािपुर
Indian Institute of Information Technology, Nagpur, Camp
Office:1st Floor Old Library Building VNIT South Ambazari Road Nagpur-4400. Website: www.iiitn.ac.in.
भारतीय सूचना प्रोद्योगिकी संस्थान, नािपुर
Indian Institute of Information Technology, Nagpur
BSNL RTTC, near TV tower, beside Balaji Temple, Seminary Hills, Nagpur-440006.
Website: www.iiitn.ac.in.
UNDERTAKING
(ANTIRANGING)
I, ………………………………………………………….…… student of ………… semester B.Tech. Roll
No……………… do hereby solemnly affirm and undertake that I shall not indulge in any form of Ragging and
that shall make determine efforts to eradicate ragging totally. I have fully understood the law prohibiting ragging
and the directions of the Supreme Court and Central/State Government in this regard as well as the UGC
*
Regulations on Curbing the Menace of Ragging in Higher Educational Institutions, 2009
I am fully aware that ragging of junior or other fellow students through physical or mental harassment is
a heinous social evil and cognizable offence, that the barbarous act of ragging may disturb the mental balance
of the students besides causing physical harm, that this may result into damaging consequence and adversely
affect his career permanently and that serious cognizance shall be taken if I am found involved in ragging or of
any complaint in this regard which may lead to my rustication from this Institute and also lodging a complaint
with the police for taking action against me under the prevailing rules. I am also aware that the use of motorized
vehicles is prohibited on the IIIT Nagpur Campus by hostellers.
Further, I undertake to follow the hostel rules as well as the directives given by hostel administration and
I shall be liable for disciplinary action, including expulsion from hostel, if I am found violating the same.
In the event of my in-eligibility to continue in the class for which I have registered, I shall vacate the
Hostel immediately.
Signature of Parent / Guardian
Signature of Student
Name : ____________________________
Name : : ____________________________
Contact no. : ________________________________
__________________________________
Date :
Place: Nagpur
* Available on Website www.ugc.ac.in
भारतीय सूचना प्रोद्योगिकी संस्थान, नािपुर
Indian Institute of Information Technology, Nagpur, Camp
Office:1st Floor Old Library Building VNIT South Ambazari Road Nagpur-4400. Website: www.iiitn.ac.in.