NATIONAL INSTITUTE OF TECHNOLOGY KARNATAKA ,

SURATHKAL
P.O. SRINIVASNAGAR, MANGALORE

Application for Admission and Allotment of Room in the Hostel

A. STUDENT DETAILS

Name: Shaswata Bose

Email: shaswata11711@gmail.com Aadhaar No: 7205-2184-6189

Roll Number: 171ME167 Registration Number: 171537

Category (OC/OB/SC/ST): General Whether PwD (Yes/No): No

Branch: Mechanical Engineering Semester: 3

Block Number: Block V Room Number: 97

Room Type: Single Mess Allotted:

Phone: 9475414354 Course: B Tech

Blood Group: O+ Date of Bir th: 15-05-1999

B. PARENT/ LOCAL GUARDIAN DETAILS:

Name of the Parent: Subrata Kumar Bose

Phone Number of the Parent: +(91)-9477083883

Email: bapi171@gmail.com

Home Address: 8/10, Shivaji Road, A-Zone, Durgapur

Name of the Local Guardian: Subrata Kumar Bose

Phone No. of the Local Guardian:

Local Guardian Address: -

C. OTHER DETAILS:

Whether he was in the hostel last year and if so, whether

he has withdrawn the deposit:

Institute fee paid, receipt number and date: 35890.0, DU71348611 dated 23-07-2017

Hostel fee paid, receipt number and date: 23000.0, DU71348701 dated 23-07-2017

DECLARATION :
I hereby declare that I have pursued and understood the Rules and Regulations of the Hostel and shall abide by
those rules and regulations as also the directions of the hostel authorities.
I hereby under take not to allow any unauthorized persons to stay in my room and in the event of any breach this
condition, I hereby under take lo pay the full damages of this account..
I hereby declare that I am fully responsible of the furniture and fixtures in the room allotted to and under take to pay
the damages to furniture and fixtures.
I hereby agree to get access to mess refund amount using ChangePay. I understand that all remaining amount will
be refunded after graduation by ChangePay.

Place: NITK Surathkal

Date: 09-07-2018 Signature of the Applicant