Ch.

Bansi Lal University, Bhiwani

Bus Pass Application Form
Sr. No.____________ Application Type: NEW/ RENEW
Affix one recent
1. Name: _________________________________________________________
passport size color
2. Father’s Name: _________________________________________________ photo here
3. Address: _______________________________________________________
(Attested by HOD/
________________________________ PIN________________________
In-Charge)
4. Department: ___________________ Roll No. ___________________
5. Phone No. _____________________ Mobile No. ________________
6. Route: Bhiwani to ________________ Via _______________________
7. Distance: ____________________ (KM)
8. Duration of Pass : SIX Months____________ to ______________ Sign within the Box for
scanning purpose
9. ID Proof Attached: 1. Aadhar Card 2. University I Card

10. Fee Deposited in ` _______________ Dated: ____________ (Attach receipt in Original)

11. Old Bus Pass Number: ______________________ Dated: ________________________________

DECLARATION:The Above information provided by me is true and correct and I shall fully responsible for the same, if it is
found incorrect at any stage and legal action can be initiated against me. I also affirm and declare that I am not working on
regular or temporary basis.

(Signature of Applicant)
Verification by the Department
It is to verify that the above applicant Mr./ Ms.____________________________ is the regular student

of the ________________ Department, studying in the __________ Semester and his /her application

for the Bus pass may be considered.

Signature of Head / In-charge (Department)

With Seal

Ch. Bansi Lal University, Bhiwani

Bus Pass Application Receipt
Sr. No.___________
Affix one recent
It is to certify that Application for Issue of Bus Pass received from passport size color
photo here
Mr./ Ms. ___________________ S/D/o Sh. ________________________
For Bus Pass From CBLU, Bhiwani to ___________________________
Via ______________________ from _____________ to _________________.
This provisional receipt is valid from _____________ to ____________.

Bus Pass Clerk In-charge (Buss Pass)

(CBLU, Bhiwani) (CBLU, Bhiwani)