..IBMT Application Form..


Residential Accommodation Form

Name :

_________________________________________

PHOTOGRAPH

Course / Year

_________________________________________

Father's / Guardian's Name

_________________________________________

Permanent Address :

_________________________________________

____________________________________________________________________

Tel / Fax

_________________________________________

Local Guardian's Name & Address

_________________________________________

___________________________________________________________________

_________________________________________________________________

Tel / Fax

_________________________________________

Mobile No :

E-mail :

Choice of meal : Veg / Non - Veg

DECLARATION

Certified that all the information given is true to the best of my knowledge. I undertake to abide by all the rules and regulation of the hostel.

Date: _______________________________

Place: _____________________________

Signature of the student

FOR OFFICE USE ONLY

Name of the loadging: _______________________________________________________

Roll No. ____________________________________________________________________

Signature of the warden ________________________

Date: _________________