Shri Dadasaheb Gawai Charitable Trusts

Vikramshila Polytechnic Darapur

Kirti Tai Girls Hostel Darapur
Phone: 9552581444/9371424842
Email: 1444office@msbte.com

HOSTEL ADMISSION FORM 2014-15

(Particulars must be filled by the candidate in his/ her own handwriting)

Form No: ___________

Date: _________________

Name of Applicant: _______________________________________________________________________________

Fathers/ Guardians Name: ________________________________________________________________________
Name of College: _________________________________________________________________________________
Department: ____________________________________ Class: ___________________________________________
DOB: ______________________

Blood Group: _____________

Caste/ Category: ______________

Permanent Home Address: _________________________________________________________________________

_______________________________________________________________________________________________
Contact No (Home):____________________________ Mobile: ____________________________________________

_____________________
Signature of Applicant
_______________________________________________________________________________________________

GUARDIAN CERTIFICATE
I __________________________________ certify that my daughter________________________________________
Is applying for the hostel accommodation on the campus of Vikramshila polytechnic Darapur with my permission and
I undertake that I will be responsible for her good behaviour during her stay in the hostel and will accept all decisions
of the hostel authorities in matter of hostel admission and discipline. I will be responsible to pay all the hostel dues,
if any, against my daughter.
Name:

_______________________________________________________________________________________

Addresss:_______________________________________________________________________________________
Contact No (1) _____________________________ Contact No (2):_________________________________

Signature