Annexure - A: Name & Signature of The Student Name & Signature of The Parent/Guardian

Annexure – A
Undertaking by the Student
I, ……………………………………………………………………………………………………
son/daughter of Mr./Ms……………………………………………………………………….…
resident of (home address) …………….……………………………………...................................
have gone through and understood the guidelines and protocols for staying in the Institute hostels.
I understand that if I am found to have given wrong information in the declaration below or
not f ol l o wi n g protocols after onboarding at the institute, I will be liable for disciplinary action.
I declare that:
 I am not suffering from any prolonged physical and mental illness.
 I understand that NIT Jalandhar has an Institute Dispensary and it will extend all available
facilities in case of a medical emergency. However, in case of medical treatment and/or
hospitalization outside the campus, the medical expenditure shall be borne by me.
 I also understand that if I am found in violation of any hostel rules, I will be liable for
appropriate disciplinary action.
 I declare that without prior approval from concerned HOD/ Chief Warden/ Hostel Warden, I
will not leave the station in any case.
 I will inform my parents / guardians, if required, in case of any exigency such as depression,
mental problem, act of indiscipline, etc.
 I understand that due to limited hostel facility, the inmates have to share the available resources
in the hostel and I have no objection for the same.
Date: …………………………
Place: ………………………...
Name & Signature of the Student Name & Signature of the Parent/Guardian
Annexure – B
Undertaking by the Parent / Guardian
Awareness of the Medical Facilities at Institute Health Centre
I, …………………………………………………………………………………………………....
Father / Mother / Guardian of Mr. / Ms. …………………………………………………………...
resident of (home address) ………………………………………................................…
………………………………………………………………………………………………………
hereby declare the following in respect of my ward for admission at Dr B R Ambedkar, National
Institute of Technology Jalandhar.
I am fully aware of the following facts:

 The Institute has a Dispensary in the campus for its community and have limited medical
facilities, which may not be adequate for treatment of chronic or serious ailments requiring
special medical infrastructure and specialization.
 In case of any medical emergency, I shall coordinate the well-being of my ward as it is the
responsibility of the parents / guardian to take care of their ward for treatment outside the
Institute campus.
 I authorize the hostel warden as signatory on my behalf if required by the Doctor in the
empaneled hospital at Jalandhar during any medical emergency or other exigency.
 I will be present physically as and when the Institute will ask me during his / her stay in
case of any extreme exigency such as serious health issue, depression, mental problem, act
of indiscipline, etc.
Despite the best efforts on part of the NIT Jalandhar, if any unforeseen event takes place to my
ward, I shall not hold Institute accountable and will not seek any financial help or compensation
for the same from any court of law.
Date: …………………………
Place: ………………………...
Name & Signature of the Parent/Guardian Name & Signature of the Student
Annexure – C
Undertaking by the Student for not owning and/or using motor driven vehicles in the
Institute Campus
I, ………………………………………………………………………………………………
son/daughter of Mr./Ms……………………………………………………………………….…
resident of (home address) ………………………………………………...................................
hereby submit an undertaking that
 I will not own or make use of motor driven vehicle for commuting inside the campus
during my stay in the Institute. If in case, I am found to violate the above undertaking
my hostel seat will stand automatically cancelled without assigning any reasons.
 Any visitor in my reference bringing a vehicle would follow the guidelines for
registering the vehicle at the Institute main gate and the hostel office, if required and I
would be liable for punishment for any violation on this account.
Date: …………………………
Place: ………………………...
Name & Signature of the Student Name & Signature of the Parent/Guardian
DOCUMENT CHECKLIST
(To be filled by the Student)
Name : ____________________________________
Roll No. : ____________________________________
Department : ____________________________________
Course (Please tick) : B. Tech. / M. Tech. / M. Sc. / MBA / Ph.D.
email ID : ____________________________________
Date and Time of arrival : _______________________ (Date)
_______________________ (Time)
I am submitting following documents to the hostel office:

1. Hostel Seat Rent Receipt (July – Dec 2023) ___________ (Yes / No)
2. Undertakings by student (Annexure A, C) ___________ (Yes / No)
3. Undertaking by parent (Annexure B) ___________ (Yes / No)
4. Mess Advance Receipt (for July – Dec 2023) ___________ (Yes / No)
5. Aadhaar Card (self-attested) ___________ (Yes / No)
6. Passport Size Photographs (2 Nos.) ___________ (Yes / No)
Student’s Signature with date: __________________
Mobile No.: ________________________
(for office use only)
Signature of Hostel Supervisor 1 Signature of Hostel Supervisor 2
Hostel Clerk

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Annexure – A

Undertaking by the Student

Undertaking by the Parent / Guardian

Awareness of the Medical Facilities at Institute Health Centre

I am fully aware of the following facts:

I am submitting following documents to the hostel office:

Student’s Signature with date: __________________

Mobile No.: ________________________

(for office use only)

Signature of Hostel Supervisor 1 Signature of Hostel Supervisor 2

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