Suitable accommodation at affordable rate is available for Working Women’s Hostel for the Persons with disabilities & Working Women’s Hostel Nibedita, Unit-V, Bhubaneswar, behind Nirman Soudha. Interest applicant may apply in prescribed form available at Nibedita Working Women’s Hostel and website www.statesocialwelfareboard.org Accommodation Rate Position 1. Dormitories per bed@850/-pm 2. Double seated per bed@1100/-pm 3. Single Room@1500/-pm 4. Guest Room@2000/-pm N.B: Contact No. 0674-2390075, 2390657, 2395629 Mob: 9777097079/7749076060 Email:[email protected] APPLICATION FORM FOR ALLOTMENT OF ACCOMODATION IN THE WORKING WOMENS HOSTEL, UNIT-V, BHUBANESWAR ---------------------------------------------------------------------------------------------------TICK YOUR HOSTEL PREFERENCE 1. NIBEDITA WORKING WOMEN’S HOSTEL 2. WWH FOR PERSON WITH DISABILITIES 1. Name………………………………………………………………………………… Married/un-married Permanent address ………………………………………………………………………………. ………………………………………………………………………………. 2. Present address ……………………………………………………………………………… Pin ………………………………………… ……………………………………………………………………………….. ………………………………………………………………………………. ……………………………………………………………………………… Pin ………………………………………… 3. Full address of Employer: i. Designation………………………………………………………………… ii. Office………………………………………………………………………….. iii. Location……………………………………………………………………… iv. Postal Address……………………………………………………………. v. Telephone No. Office…………………………………………………Res…………………………….. vi. District………………………………………………………………………. N.B: Any change of address must be communicated by the applicant. 4. Total Emoluments: i. Pay……………………………………………………………………………… ii. Special Pay…………………………………………………………………. iii. D.A./A.D.A………………………………………………………………… iv. Other Allowances………………………………………………………. N.B: Certificate to the effect of monthly emolument be produced from the employer. 5. Name of Father/Mother………………………………………………………………………………………………...... With full address………………………………………………………………………………………………………………….. 6. Name of Husband if married …………………………………………………………………………………………. With full address………………………………………………………………………………………………………………….. Contd...P-2 7. Name of the local guardian with full address i. Name………………………………………………………………………………………………………………………… ii. Relationship with applicant……………………………………………………………………………………… iii. Profession………………………………………………………………………………………………………………… iv. Qr. No. /(ouse No./Plot No. …………………………………………………………………………………… v. Area…………………………………………………………………………………………………………………………… vi. Telephone No. Office…………………………………………….. Res. ………………………………………… 8. Name of surety will full particulars: i. Name…………………………………………………………………………………... ii. Permanent address ………………………………………………………………………………………………. ……………………………………………………………………………………………… ……………………………………………………………………………………………… iii. Present address ………………………………………………………….... ………………………………………………………………………………………………. ………………………………………………………………………………………………. iv. Telephone No. Office…………………………………………………………… Res ………………………………………….………………... 9. i.The Person/Persons to be notified in case of temporary. ii.whether he/she will function as surrender in case of necessity. iii.whether you can with the local guarantor in case of necessity sword/holiday. 10. Normal duty hours of the place of work N:B : Please indicate i.Normal hours for leaving Hostel for official work. ii.Normal hours for returning to Hostel. iii.In case you are allotted with night duty by the employer and certificate to this effect should be produced from the employer iv.Whether Govt. service/Private/Public Undertaking/Corporation. 11. Type of seat applied for: a Single room………………………….. b Double room………………………………………………. c Dormitory………………………………. In case and should norms: Indicate preference: a)Miss/ Mrs. b) c) N.B: The application should be prepared to accept any allotment. Declaration: 12. I have read the Working Women’s Hostel Rules, 1987 and hereby undertake to abide them during stay in the said Hostel. Signature of the Local Guardian With address Signature of the Applicant Contd…P-3 Following documents to be submitted along with the application Form:       Employer Certificate Conduct Certificate Medical Fitness Certificate Court Affidavit (To obey the Hostel Rules and Regulation) Two Passport size Photograph. Applicants for WWH (for person with disability) are required to submit supportive proof. DECLARATION OF THE SURETY I Sri………………………………………………………………………………………….of Plot No./Qrs. No …………………………………………of town/NAC of ………………………………………………….hereby declare that I have read the working women’s hostel rules and that I/We shall be responsible for the good behavior of Ms………………….…………………………………………………………………………. W/O./D/O……………………………………………………………………………………………………………………………….. of village……………………………………………………………….Dist…………………………………………………………… during her period of stay in the working women’s hostel. In case of any undisciplined conduct the authorities concerned have the right to expel /discharge her from the Hostel. In the event of her being expelled/discharged from the Hostel or on defaulting in payment of Hostel and Mess dues. I undertake to pay such sum of sums on a one time or/within 7 day to the managing committee of the Hostel. I also undertake to pay the said committee such sum of sums on or spent to evict her in case of her failure to leave the Hostel on being expelled. Signature of the Applicant Date: Signature with address Undertaking from Employer Smt/Miss……………………………………………………………………………………………………………………….. Daughter/Wife of………………………………………………………………………………………………………….. Of village………………………………………….. P.O. …………………………………… P.S………………….….. In the District of…………………………………………………………………………………. is an employee of this……………………………………………………………………………………………………………..………and drawing gross emoluments of ` ……………………………………….per month. I /this Office/ Undertaking/Department undertake to deduct and pay to the Hostel Management Committee. Salary of the employee al dues which has/is required to pay the hostel and falls of defaulter in paying. In case she is removed or discharged from service this………………………………………………………………………………………………………………………..………. undertake to deduct and pay from her terminal dues, any amount payable to the Management Committee. Signed for and behalf of (Seal)