KARNATAKA INSTITUTE OF MEDICAL SCIENCES HUBLI

OFFICE OF WARDEN KIMS HUBLI 580022

BOYS/LADIES HOSTEL
(for office use only)
APPLICATION FORM
FOR HOSTEL FACILITY Student File No.:________________________
(For New Candidates)
University Registration No:_______________
Photo
Hostel Registration No:__________________

Hostel: _______________________________

Room No: __________Seater: ___________

Hostel Fee:____________________________
Important Instructions
 Please refer to the Guidelines in the Admission Prospectus for any details.
 No column should be left blank. Write N.A. if not applicable.
 All the details should be filled in Block Letters
 Duly filled in Undertaking Form is to be signed by the candidate with blue/ black pen and duly countersigned by the
parent/ guardian.

NAME ____________________________________________________________________DOB_______ /______ _/________

COURSE STUDYING ________________ DEPT_________________TERM:-FROM_______________TO_______________

CAST/SUBCASTE:____________________MOBILE No.__________________________ E mail:_______________________

AADHAR NO:_____________________________________ PAN CARD No._______________________________________

FATHER NAME: ___________________________________DEPT___________________PLACE_______________________

MOBILE No.;______________________________________Email: ______________________________________________

MOTHER NAME:___________________________________DEPT___________________PLACE______________________

MOBILE No._______________________________________E mail: ______________________________________________

Permanent Address Correspondence Address (If different forms)

Address _______________________________________________ Address _____________________________________________________

______________________________________________________ ____________________________________________________

Town / City ___________________________________________ Town / City __________________________________________________

District _______________________________________________ District ______________________________________________________

State / UT ___________________________________________ State / UT __________________________________________________

Country ___________________Pin/Zip________ ____________ Country ________________________________Pin/Zip _______________

(Signature of the Student)

(Application farm should print in front back sides)

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 UNDERTAKING TO BE SIGNED BY THE PARENT / GUARDIAN

I,___________________________________________S/o/D/o_____________________________

______________________________________do hereby solemnly affirm and undertake that:

1. My son/daughter/ ward, _________________________________________________________ has
submitted this undertaking for hostel facility with full understanding and my permission; and I shall
hold myself responsible for his/her good conduct and behavior as a student of KIMS HUBLI and
adherence to the Provisions.
2. I shall hold myself responsible for payment of all his/her fee and other charges during his/her stay in
the hostel and pending dues, penalty, etc.
3. I shall myself, be responsible for any sort of liability arising and any civil or criminal case against
my son/daughter/ward during the course of study.
4. I endorse the undertaking given by my son/daughter /ward.
5. I will not allow my son/daughter/ward to use any vehicle in the campus throughout his/ her stay in
the hostel till the completion of their course.

Place:……………………………………
…………………………………………….(Full signature of the Parent/Gaurdian)
Name…………………………………………….
Relationship with the Student……………………

INDEMNIFICATION

I hereby indemnify the Administration of KIMS HUBLI, against all rights and claims by myself, my
dependents, next of kin or other legal representatives for compensation for damages or disability arising out of
personal injury or death due to any reason during the course of my study (on campus or off campus) in KIMS
HUBLI INSTITUTE including during study, industrial visits, trainings, tours, conduct of practical, working in
laboratories or workshops, stay in hostel, traveling or otherwise (within or outside the precincts of the Institute).

Place: ……………………………
Date: ……………………………
(Signature of the Student)
(To be countersigned by the Parent/Guardian)
(Full signature of the Parent/Guardian)

Name………………………………………………
Relationship with the Student …………………….

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 (Rs. 100/-Bond Paper)
UNDERTAKING FOR HOSTEL FACILITY BY THE STUDENT

I, ______________________________________________S/o/ D/o___________________

______________________________________________do hereby solemnly affirm and undertake that:

1. I shall abide by all the provisions of KIMS HUBLI and Govt. Act, Statutes, Guidelines, Manuals,
Code, Circulars etc. in force and as amended from time to time (hereinafter jointly referred to as “the
Provisions”) of and/or framed by the Government, KIMS Institutions .
2. The Management will be at liberty to impose any penalty or any disciplinary action(s) on me in case
I am found guilty of any sort of misconduct, indiscipline, disobedience or malpractice within or
outside the precincts of the Institution, or any act which is detrimental to the interest of the
Institution. The Management, in such case, may discontinue my stay in the Institution and I shall not
be entitled for any refund of admission fee, hostel fee, bus fee and any other fee / charges paid to the
Institution and I shall also be liable to pay the pending fee, dues, penalty, etc.
3. I shall retain the hostel accommodation for the full academic course and if due to any reason i leave
the hostel during the academic course, I shall pay the hostel charges for full course.
4. I shall not be entitled to claim my admission to the hostel as a matter of right.
5. I am aware that ragging is a criminal offence and is strictly prohibited. I shall not indulge directly or
indirectly in any act of ragging on the campus, in hostels or outside the campus of the Institution. If I
indulge in ragging, the Management may take appropriate disciplinary action (including
rustication/expulsion from the hostel and/or the Institution) against me and further legal action as per
law of land.
6. I shall not possess, use or deal with any kind of intoxicating material including alcohol, drugs and
any kindof sedative materials and on being found guilty, the Institution may take any disciplinary
action(s), including rustication/expulsion, against me.
7. I shall not possess, use or abet the use of any kind of weapons including sticks, rods, explosives,
firework or any such material and on being found guilty, the Institution may take any disciplinary
action(s), including rustication/expulsion, against me.
8. I shall be liable to pay for any damage caused by me to the property of the Institution either alone or
jointly with others and face disciplinary action.
9. I do not have the tendency, and shall not make any attempt, to commit suicide or abetting or inciting
any other person to commit suicide or anything unwarranted and /or prohibited by law or otherwise
and shall not give any sort of threats to commit suicide or likewise and / or being found guilty of the
aforesaid action, I myself shall be responsible for any consequences under law and the
expulsion/rustication from the Institution and any other legal action under the law of land. The
Management shall not be responsible for the same.

(Signature of the Student)

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10. I am medically fit and have no communicable or chronic disease, I shall pay for any expenditure
incurred by the Institution on my treatment for any sickness or personal injury due to any reason
during the course of my study at the Institution.
11. I shall not keep excess cash and valuables within the hostel and in case of any loss or damage of
cash or valuables, including mobile phones, PC, laptop or any other personal belongings, the
Institution shall not be responsible for any kind of compensation.
12. I agree to vacate the hostel in case of any requirement of the Institution for some specific period for
any reasons including accommodating guests, delegates, participants of any event, for maintenance
work etc.
13. I shall not collect any money from any student(s), employee(s) or other person(s) for any purpose
including donations, contributions/gathering without the written approval of the Institution.
14. The Management has the full authority to call/send for official/academic purposes any time even
during holidays or for early or delayed stays even during nights.
15. The Management has the full authority for the inspection of the room, bags, almirahs or any of my
personal belongings at any time.
16. I understand that hostel, allotted at the time of admission or otherwise, may be shifted to other
hostel, at any time and the allotted room, floor and other facilities in the hostel may also be changed
at any time, as decided by The Management.
17. I shall not allow any unauthorized person to enter or stay in my room.
18. I shall myself take precautions against insect-bites, dog-bites, snake-bites, animal-bites and such
other infections and diseases and shall carry the first –aid kits every time and the University shall not
be liable for such infections and diseases.
19. I shall not misuse electricity by using electrical gadgets like irons, heaters.
20. I understand that the hostel fee does not include the electricity charges/amount and I shall be liable
to pay the electricity charges/amount separately in addition to the hostel fee as decided by The
Management.
21. I understand that the hot water supply shall be available in winter only for fixed timings in the
washrooms, as decided by The Management.
22. If I absent myself from the Institution without permission for long period [ i.e. more than 4 days ], I
am liable for disciplinary action, which may amount to my rustication/expulsion from the Institution.
23. If declared ineligible for appearing in any examination of the University, on account of shortage of
attendance or any other reason whatsoever or if ordered by the Institution authorities at any time, I
shall vacate the hostel immediately. Readmission to hostel in the forthcoming term/semester may be
allowed only at the sole discretion of the Management.
24. All type of charges and fee as charged by the Institution are subject to revision from time totime.

(Signature of the Student)

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25. For any unforeseen issues arising, that is not covered by this Undertaking, or in respect of all the
matters, not expressly provided herein, the Institution may take an appropriate decision that shall be
final and binding on me and all other concerned.
26. I am giving this undertaking with full understanding and state that the information given by me
above are true and complete to the best of my knowledge and belief and the certificates, documents
and other information submitted by me are genuine and nothing has been concealed/suppressed. I
understand that if any of the statements made by me above is found incorrect, I shall be liable to
such disciplinary action(s) and/ or penalty as may be decided by the Management, notwithstanding
legal action under the law of the land. In such case, the hostel fee and other charges deposited by me
shall be forfeited.
27. The Management reserves the right to frame, amend, revoke or repeal the Provisions including
hostel timings and that will be effective and binding on all concerned, as decided by the
Management from time to time.
28. I will not use any vehicle in the campus throughout the stay in the hostel till the completion of
course.
29. In-service PG’s must pay mess bill in advance for one year, at the beginning of the academic year.
30. Not getting stipend should not be the reason for not paying the Room rent and Mess bills every
month. There should be sufficient bank balance, approximately Rs. six thousand.
31. Mess bills and Room rent are being deducted from your Bank accounts compulsorily.
32. Should be ready for sharing Room with other inmates (Maximum-2)
33. Birthday celebrations, loud shouting’s and abnormal behaviors etc., are totally prohibited in Hostels.
34. Students deposit amount will refund after course completion.

(Signature of the Student)

Place: ……………………………
………………………….
Date: ……………………………

RAGGING IS STRICTLY PROHIBITED

As per the Supreme Court judgment in VishwaJagriti Mission v. Central Government and Others
(2001) 6 SCC 577, AND as per Act of Govt. of AP w.r.t ragging, ragging is a cognizable criminal
offence and is Strictly prohibited. If any incident of ragging comes to the notice of the University,
the concerned student shall be given liberty to explain and if his explanation is not found
satisfactory, the University would Expel him from the University.

(Signature of the Student)

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 ENCLOSURES BEFORE OCCUPYING HOSTEL ROOM

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1) C.E.T/NEET Allotment Xerox Copy

2) Collage Fee Receipt Xerox Copy

3) Office Memorandum Xerox Copy

4) 100 rupee Bond Paper (Attested by Notary)

(Ist party Student Name, 2nd party Warden Boys Hosel, KIMS, Hubli.)

5) Aadhar Card Xerox copy-1

6) 3 Pass Port size photo.

7) 1 A-4 Size Plastic Envelope(cover)

8) Application form should print in front back

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