NATIONAL INSTITUTE OF TECHNOLOGY KARNATAKA , 2929?

SURATHKAL 1482657689
P.O. SRINIVASNAGAR, MANGALORE
Application for Admission and Allotment of Room in the Hostel

A. STUDENT DETAILS

Name: V.Saicharan

Email: vsaicharan1998@gmail.com Aadhaar No: 5637-1206-7216

Roll Number: 16CO150 Registration Number: 166040

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

Computer Science and

Branch: Semester: 5
Engineering

Block Number: Mega Tower II Room Number: B302

Room Type: Single Mess Allotted:

Phone: 8971514770 Course: B Tech

Blood Group: A+ Date of Bir th: 02-06-1998

B. PARENT/ LOCAL GUARDIAN DETAILS:

Name of the Parent: GR Viswanath

Phone Number of the Parent:

Email: grv@chri.in

Home Address: NO 8, KEMPANNA LAYOUT, RAMCHANDRAURA, BANGALORE- 560 013

Name of the Local Guardian: G R VISWANATH

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he has withdrawn the deposit: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:

Hostel fee paid, receipt number and date:

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: 10-07-2018 Signature of the Applicant