Banaras Hindu University
Application Form for Allotment of Hostel/City Delegacy - Cum Dossier Form
for Allotment of Hostel/City Delegacy - Cum Dossier (To be Filled in Quadruplicate by All Students)
The Dean,
Faculty of _________
Banaras Hindu University
Madam,
I am seeking admission to : Course _____________________ Year __________________ Subject/Group ..................................................................................................................................... I requestSubject/Group ..................................................................................................................................... I request you to allot me a seat in the Hostel/I seek permission stay city (Tick whichever is applicable).
I promise to abide by all the rules of discipline University, failing which any disciplinary action may be taken against me, including expulsion from the University.
Yours faithfully,
(Signature of the applicant)
Date: .......................Name: ..........................................
Residence during previous Session (If a BHU student)Residence during previous Session (If a BHU student)
Name of the Hostel (if hosteller) : ........................................................................................................... .........If Block No. .............................................. Room ........................................................................................ If city delegacy student, Name of the Delegacy .....................................................................................................
For Office Use Only
Admit Km./Smt. ....................................................................................................................................... as Hostel resident/ as a Day scholar in city
Hostel/City .......................................................................................... (Signature with seal)
Dated: ............................. Dean
Residence allotted (Hostel with Room Number / Delegacy) ......................................................................... Fee Receipt No. ........................................................... Dated...............................................
City DelegacyHostel Warden / Chief Warden,
Note: Admission to a Course of Study Does Not Guarantee Accommodation in the Hostel
Affix selfAffix attested passport sized passport photo
PARTICULAR TO BE FILLED BY THE APPLICANT
A. UET/PET Roll No. ............................ B. Enrollment No. .............................
(for First Year students of a course) (If already enrolled)
1. Name of the Applicant ...................................................................................................................................
2. Sex (Male/Female) .........................................................................................................................................
3. Date of Birth ...................................................................................................................................................
4. Whether belongs to SC/ST/OBC/OBC Minority: Yes/No. ............................, If yes, Category ......................
5. Blood Group (If known) ................................................................................................................................
6. Identification marks .......................................................................................................................................
7. Any specific medical problem(s) ...................................................................................................................
8. Father's Name .......................................................................................................................................... ......
9. Mother's Name ...............................................................................................................................................
10. Husband's Name (in case of married women) ...............................................................................................
11. Guardian's Name (if other than Father) ........................................................................................................
12. Relation of candidate with guardian ............................................................................................................
13. Permanent Address (Mention State, District, Town, Village & Post clearly)
.......................................................................................................................................................................
.......................................................................................................................................................................
14. Police Station ..............................................................................................................................................
15. Name of the nearest Railway Station ............................................................................................................
16. Local Address (in the case city delegacy students) .......................................................................................
...................................................................................................................................................................
...................................................................................................................................................................
17. Whether ever Convicted/ Rusticated/ Debarred / Expelled / Suspended ? YES / NO
If "YES" give details.
...................................................................................................................................................................
...................................................................................................................................................................
18. Name, Address and Telephone Nos. (if any) of person to be contacted in emergency.
(a) Outside Varanasi : ....................................................................................................................................
.....................................................................................................................................................
Phone: ....................................................... Mobile .....................................................................
Email id: ………………………………………………………
(b) Inside Varanasi : .....................................................................................................................................
.....................................................................................................................................................
Phone: ....................................................... Mobile .....................................................................
Email id: ………………………………………………………
Date: Signature of the Applicant