Application Form

222123, Appx.'A' (Refers to Para 19)

:
Tele 224663. Grams : NIMOUNT
Std Code : 01374. Fax : (01374)-223344
ISD 911374- e-mail : nimindia@rediffmail.com
:
Code 222123.

NEHRU INSTITUTE OF MOUNTAINEERING

Uttarkashi - 249193 INDIA
APPLICATION FORM
(TO BE FILLED OR TYPED IN BLOCK LETTERS)

NOTE : INCOMPLETE FORMS WILL NOT BE ACCEPTED

Affix Affix
Photograph Photograph
here here
(1) (2)

1. Name__________________________________________________.

2. Date of Birth (in words)

___________________________________________.

3.
Occupation______________________________________________________.

4. Permanent
Address_______________________________________________.
Pin : - ________________________.

Telephone with STD Code_______________E-mail

______________________.

5. Telephone with address and next of kin, Parent/Guardian (in the event of an
accident)

Name__________________________________________________.

Address________________________________________________________.

Pin Code_____________________. Tele No. _________________________.

CONFIRMATION (OFFICE COPY) Latest Postal Address on which
Confirmation will be dispatched
(To be filled by candidate in Block Letters)
(To be filled by candidate in
Name___________________________________. Block-Letters)

Postal Address: To,

____________________________ ___________________________
________________________________________ _
_
________________________________________ ___________________________
_. _
Pin______________.
___________________________
(For official use only) _

Seat Confirmed / Provisionally reserved in Course ___________________________

Ser No.__________. _

Duration ___________________________
(From)____________(To)____________. _

Date of arrival at ___________________________

NIM_______________________. _

Date of departure from ___________________________

NIM__________________. _

Fee Details: DD ___________________________

No_____________Dated___________________. _

Amount____________is here by acknowledged.

Requirement( if any)

(a)_____________________

(b)______________________

Please submit the above within one month for

final confirmation.