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: ____________

Important Instructions Hostel Fee:____________________________

 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: _______________________________________________________________________________________

MOBILE No.;___________________________________________________________________________________________

MOTHER NAME:_______________________________________________________________________________________

1.KEA admission order No.

2. KIMS Memo No.

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)

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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/Guardian)
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 …………………….

Sl. NAME OF THE SYNDICATE BANK SYNDICATE BANK AMOUNT

No BANK DD PARTICULARS IFSC CODE NO. ACCOUNT NO.
1. WARDEN CHARAK BOYS HOSTEL KIMS CNRB0011241 12412010040140 9000
2. VIVEK BOYS HOSTEL KIMS HUBBALLI. CNRB0011241 12412200000113 6500
3. HOSTEL FEE COLLECTION CNRB0011241 12412190002457 10000
4. DIRECTOR /FINANCIAL ADVISOR CNRB0011241 12412200012549 11300
Total 36,800
UG Admission Fee Structure (2020-21) (Tobe paid through Bank challen only)

ADMISSION APPROVAL

Place:
Date: Signature & Seal of warden
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