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Application No:____________________(For Office Use)

NETAJI SUBHAS UNIVERSITY OF TECHNOLOGY


AZAD HIND FAUJ MARG, SECTOR - 3
DWARKA, NEW DELHI-110078

BH-III HOSTEL
HOSTEL REQUISITION FORM

NAME RISHABH SRIVASTAV

MOBILE NO. / Email Id of Student 9953482523 / rsrivastav54@gmail.com

JEE ROLL NO. 11603004

NSUT ROLL NO. 2016UIC3085

BRANCH INSTRUMENTATION AND CONTROL ENGINEERING

CATEGORY GN SUB CATEGORY GN

ADMISSION TYPE JEE REGION DELHI

YEAR 2016

SEMESTER 7

RESIDENTIAL ADDRESS Flat No.5211, ATS Dolce, Plot No. GH-12A,


SECTOR-ZETA-01, GREATER NOIDA,
GAUTAM BUDDHA NAGAR
UTTAR PRADESH
INDIA
201301

LAND LINE PHONE NO 01207184836

DISTANCE FROM NSUT 62.00 (In Km)


 
Date:           (SIGNATURE OF STUDENT)

Acknowledgement Slip

Name: RISHABH SRIVASTAV

NSUT Roll No: 2016UIC3085

Branch: INSTRUMENTATION AND CONTROL ENGINEERING

Date of Submission of Application:

(Signature of Warden)
NETAJI SUBHAS UNIVERSITY OF TECHNOLOGY
AZAD HIND FAUJ MARG, SECTOR - 3
DWARKA, NEW DELHI-110078

BH-III HOSTEL
STUDENT RECORD FORM
(To be submitted at the time of Hostel admission)
1. NAME RISHABH SRIVASTAV

2. NSUT ROLL NO. 2016UIC3085

3. ROOM NO. BH-III/A/4/405/B1

4. BRANCH INSTRUMENTATION AND CONTROL ENGINEERING

5. CATEGORY GN SUB CATEGORY GN

6. ADMISSION TYPE JEE REGION DELHI

7. SEMESTER 7

8. DATE OF JOINING .........../.........../2016

9. BLOOD GROUP A+

10. MOBILE NO. / Email Id of Student 9953482523 / rsrivastav54@gmail.com

11.NAME AND TELEPHONE NUMBER OF MOTHER / FATHER/ LOCAL GUARDIAN


MOTHER FATHER LOCAL GUARDIAN
Name DEEPALI SRIVASTAVA PREM SHANKAR SRIVASTAVA
Phone No. 01207184836 9968076979
Email ID rsrivastav54@yahoo.in pss_18@yahoo.com

12.ADDRESS
Communication Address Permanent Address LOCAL GUARDIAN
Flat No.5211, ATS Dolce, Plot No. GH-12A, Flat No.5211, ATS Dolce, Plot No. GH-12A,
SECTOR-ZETA-01, GREATER NOIDA, SECTOR-ZETA-01, GREATER NOIDA,
GAUTAM BUDDHA NAGAR GAUTAM BUDDHA NAGAR,
UTTAR PRADESH, INDIA, Pin: 201301 UTTAR PRADESH, INDIA, Pin:

13. Mention any chronic illness/medical problem that may need urgent medical attention
NIL

We hereby state that all the information given above is true to the best of our knowledge.

SIGNATURE OF STUDENT
SIGNATURE OF LOCAL GUARDIAN SIGNATURE OF PARENT
UNDERTAKING
   I, RISHABH SRIVASTAV SON/DAUGHTER/Ward of Mr/Mrs PREM SHANKAR SRIVASTAVA Roll.No 2016UIC3085
Room No BH-III/A/4/405/B1 hereby give an undertaking that

 1. I understand that the institute will not be responsible for any mishappening outside the institute premises.

 2. I understand that I will take care of my belongings and the institute will not be responsible for any theft in my
hostel room.

 3. I have received a copy of the hostel rules and will abide by them.

 4. I have been allotted present room for current academic year only and will vacate it at the end of this academic
year as per the norms of inistitute.

 5. I am aware that the hostel fee paid by me will not be refunded after confirmation of the room alloted to me.

 6. I am also aware of the fact that at any stage, if I am found violating the above undertaking, the hostel authorities
of NSUT, New Delhi may take suitable action that includes cancellation of hostel accommodation with immediate
effect and even expelling me from the institute.

 (Signature of Student)
NETAJI SUBHAS UNIVERSITY OF TECHNOLOGY
AZAD HIND FAUJ MARG, SECTOR - 3
DWARKA,NEW DELHI-110078

BH-III HOSTEL
STUDENT RECORD FORM (DUPLICATE)
(To be submitted at the time of Hostel admission)

1. NAME RISHABH SRIVASTAV

2. NSUT ROLL NO. 2016UIC3085

3. ROOM NO. BH-III/A/4/405/B1

4. BRANCH INSTRUMENTATION AND CONTROL ENGINEERING

5. CATEGORY GN SUB CATEGORY GN

6. ADMISSION TYPE JEE REGION DELHI

7. YEAR 2016

8. SEMESTER 7

9. DATE OF JOINING
............/.........../2016

10. BLOOD GROUP A+

11. MOBILE NO. / Email Id of Student 9953482523 / rsrivastav54@gmail.com

12.NAME AND TELEPHONE NUMBER OF MOTHER / FATHER/ LOCAL GUARDIAN


MOTHER FATHER LOCAL GUARDIAN
Name DEEPALI SRIVASTAVA PREM SHANKAR SRIVASTAVA
Phone No. 01207184836 9968076979
Email ID rsrivastav54@yahoo.in pss_18@yahoo.com

13.ADDRESS
Communication Address Permanent Address Local Guardian
Flat No.5211, ATS Dolce, Plot No. GH-12A, Flat No.5211, ATS Dolce, Plot No. GH-12A,
SECTOR-ZETA-01, GREATER NOIDA, SECTOR-ZETA-01, GREATER NOIDA,
GAUTAM BUDDHA NAGAR GAUTAM BUDDHA NAGAR,
UTTAR PRADESH, INDIA, Pin: 201301 UTTAR PRADESH, INDIA, Pin:

14. Mention any chronic illness/medical problem that may need urgent medical attention

We hereby state that all the information given above is true to the best of our knowledge.

SIGNATURE OF STUDENT
SIGNATURE OF LOCAL GUARDIAN SIGNATURE OF PARENT
NETAJI SUBHAS UNIVERSITY OF TECHNOLOGY
AZAD HIND FAUJ MARG, SECTOR - 3
DWARKA, NEW DELHI-110078

BH-III HOSTEL

STUDENT RECORD FORM


(To be submitted at the time of Hostel admission)
NAME RISHABH SRIVASTAV

NSUT ROLL NO 2016UIC3085

BRANCH INSTRUMENTATION AND CONTROL ENGINEERING

 1. BLOOD DONATION

  In case of emergency are you willing to donate blood


BLOOD GROUP   A+

CONTACT No   9953482523

 2. SPORTS: Which sports (indoor/outdoor) are you interested

Cricket, Football,Table Tennis, Basket Ball, Badminton

 3. CULTURAL: Are you interested in participating in


 i. Dance No  
 ii. Vocal Yes
 iii. Instrumental Yes
 iv. Dramatic Yes

 4. FINE ART   Yes

 5. Any other curricular activity which is of your interest

  Dramatics

(Signature of Student)

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