MAHARSHI GURUKUL

+2 sc. Residencial College, Niladreebihar lane-4, Gunupur, ph:06857-251057

REGISTRATION FORM FOR ADMISSION IN TO SUMMER COURSE-2017

1. Name:_______________________________________________________________________________________
2. Date of Birth:__________________________________________________ Sex (Male/Female) [ ]
3. Fathers Name:_______________________________________ Occupation:_______________________
4. Mothers Name:______________________________________ Occupation:_______________________
5. Name of the High School:__________________________________________________________________
6. H.S.C. Roll no:______________________ Marks secured in test Exam:______________
7. Coaching Center:___________________________________________________________________________
8. Address for corespondance:______________________________________________________________
_____________________________________________________________

9. Mobil no:

10. Status : Residential/ Non- Residential [ ]

I hereby fully endrose the information given Submitted by me

by our Child/ward

Signature of Parents/ Guardian Full Signature of the applicant

Date:_____________________________ Date:____________________________

FOR OFFICE USE

Received by:_______________________________________________________________________________

ADMISSION-INCHARGE
MAHARSHI GURUKUL
+2 Sc. Residential College
 MAHARSHI GURUKUL
+2 sc. Residencial College, Niladreebihar lane-4, Gunupur, ph:06857-251057

To
The principal
MAHARSHI GURUKUL, ODISHA
Respected Sir,
Im interested to stay in the hostel provided by the institution.
Please allot a seat for me as per availability. My personal detail is given
as bellow.
FOR OFFICE USE
Student File No: _______________Hostel Registration No: ______________ Hostel:______________
Room No:__________________ Seated :___________________ Hostel Fee:_________________________

Important Instruction
All fields shall be filled in BLOCK LETTERS.
No column shall be left blank, Write NA. If not applicable.

Student Name:________________________________________________________________________________
Class:_______________ Year/ Semester:________________ Roll No:_________________

ADRESS FOR COMUNICATION

PERMANENT
Address :________________________________
Town / City :________________________________
Police Station:________________________________
District :________________________________
Zip/ Pin code:________________________________
PRESENT
Address :______________________________
Town / City :______________________________
Police Station:______________________________
District :______________________________
Zip/ Pin code:_______________________________

TELIPHONE NOS FOR COMUNICATION

FATHER
Residence:____________________________
Office :____________________________
Mobil no :____________________________
E-mail id :____________________________
MOTHER
Residence:____________________________
Office :____________________________
Mobil no :____________________________
E-mail id :____________________________
 (Signature of the student)

UNDERTAKING SUBMITED BY THE HOSTEL STUDENT

I, ________________________________ S/o/ D/o____________________________ bearing roll no
___________do hereby solemnly affirm and under take that:
1. I shall not claim my admission to the hostel as a matter of right.
2. I am aware that ragging is a criminal offence and shall not indulge myself directly or indirectly in
any act of ragging. If so, institute may take appropriate disciplinary against me.
3. I shall pay and retain the hostel accommodation at least for one year/ academic session. If I
leave the hostel in between, I will pay the hostel fee for that academic year before leaving the
hostel.
4. I shall not process, use or deal with any kind of intoxicating material including alcohol , Gutka,
tobacco, cigarettes or any other arms/ weapons or any cell phones, if detected, the institute
may take disciplinary action(s).
5. I shall be liable to pay for any damage caused by me to the property of the institution either
alone or jointly with others and face disciplinary action.
6. I do not have tendency, and shall not make any attempt to commit suicide or abetting or
inciting any other person to commit suicide. If found guilty, I shall be responsible for any
consequences liable for legal actions.
7. I am medically fit, have no communicable diseases, and diseases like fits. I shall pay for any
expenditure incurred by the institution on my treatment for any sickness or personal injury
during the course of my study at the institution.
8. In case of any theft, loss or damage of case of valuable personal belonging the institution shall
not be responsible for any kind of compassion.
9. If instructed, I am ready to vacate and or change the hostel room as and when required by the
institution.
10. The institution authorities are allowed to inspect my room at any time.
11. I shall not allow any day-scholar student/ unauthorized person to stay in my room at any time.
12. I will take precaution against insect-bites, dog-bites, snake-bites, animal-bites and such other
infection.
13. I will not use electrical gadgets like hot press (iron), heaters, audio player, etc.
14. I will switch off the light & fans whenever those will not be in use.
15. I will keep my room tidy and maintain neatness although.
16. I will not remain absent from the hostel/ institution without prior approval.
I have read all the rule/ instruction of the hostel and agreed to abide by all.
Place :_______________
Date :_______________ (Signature of the Student)

UNDERTAKING TO BE SIGNED BY THE PARENTS

I _______________________________parents of ___________________________________do
Hereby undertake that:
1. My word, has submitted the undertaking for Hostel Facility with my express permission: and I
shall be responsible for his/her good conduct and behavior as a student of the MAHARSHI
GURUKUL+2 Sc. College and adherence to the Provisions.
2. I am responsible for payment of all his/ her fee and other charges during stay in the hostel and
pending dues, penalty, etc.
Place:__________________
(Full Signature of the Parent)