BDS GIRLS PAYING GUEST Affix a recent

Passport size
Photograph
Milanpur,Dergaon,
Near Radient HS College,785614
M:-9101541394

PERSONAL DETAILS

1. Name of the Student:- ____________________________________

2. Aadhar Card No.:- _______________________________________
3. College Name:- ________________________________________
________________________________________
4.Contact No.:- ________________________________________
5.Blood Group:- ________________________________________

PARENT DETAILS

1. Father’s Name:- ________________________________________

2. Mother’s Name:- ________________________________________

3. Parmanent Address:-_______________________________________

_______________________________________

4.Address for Correspondence:- ________________________________

_______________________________
5.Telephone No.:- __________________________________

LOCAL GUARDIAN’S DETAILS

1. Name of the LG:-_____________________________________

2. Relation of LG with student:-____________________________

3. Resident Address:-_____________________________________

_______________________________________

4. Telephone No.:-_______________________________________

I,_________________________(Name of the Father/ Parent),hereby

declare that____________________________(Name of the nominated
Guardian) and I nominate him/ him her as a Local Guardian of my
ward____________________________________(Name of the student).
Certified that:-

 We shall undertake to pay all dues in respect of my ward.

 We take full responsibility of your ward and assure that he/ she
would maintain desired discipline and abide by all rules and
Regulations of PG
 We assure that in case of misconduct, we shall arrange/ make
alternate arrangement for stay of our ward within 48hrs of the
receipt of information from School/College.
__________________ _____________________
Signature of the Parent/Guardian Signature of the Local Guardian

Date:______________________ Date:______________________

Place:-_____________________ Place:-_____________________