TEZPUR UNIVERSITY

NAPAAM, TEZPUR 784028

Application for Hostel withdrawal
(Student will submit the filled in form at the time of withdrawal from the Hostel
1. Name in full (Block latters)
2. Roll No & Department
3. Designation (for Project staff)
4. Purpose of withdrawal
5. Recommendation for withdrawal by

i) HoD

ii) Warden

iii)Guardian (optional)

iii) Local Guardian

I hereby withdraw from the Hostel (name of Hostel) on

..due the reason mentioned above. I have no outstanding, in any form, payable to
Tezpur University
Full signature of the students
Date:

Place:

Contact No..
Email ID
Postal Address

-------------------------------------------------------------------------------------------------------------------------------------------OFFICIAL USE
Clearance Certificate
It is verified and found that
i) The above student has no outstanding
ii) The above student has outstanding as

Hostel Warden
Tezpur University
It is verified and found that
i) The above student has no outstanding
ii) The above student has outstanding as

Sports Officer/Asst. Director of Sports

Tezpur University

It is verified and found that

i) The above student has no outstanding
ii) The above student has outstanding as

Cultural Officer
Tezpur University
It is verified and found that
i) The above student has no outstanding
ii) The above student has outstanding as

Dean Students Welfare

Tezpur University

(To be submitted in duplicate: Original shall be submitted to the Warden while Duplicate is to be kept by the Office of DSW)