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Model Engineering College Thrikkakara

Declaration form for WiFi Connectivity


(Student Registration )

General Information

Name

Course B.Tech/M.Tech /P.hD

Branch

Roll Number

ID card No.
Course Duration From To

Contact Email id:

Technical Information
Type of Device Laptop/Netbook

Make, Model & Serial No.

MAC Address (Ethernet)

MAC Address (wireless )

Operating System Windows/Unix/Mac/Dual/others(specify)

I hereby declare that the above information given by me is true and correct . I will be responsible
for the Internet transactions happen through above said MAC address.

Date: Name and Signature of the Student

Name and Signature of the Staff In Charge Signature of the HOD

For the Use of Computer Lab

Date of MAC Registration

Proxy Servers on with the MAC is added Proxy2 /Proxy3 / Proxy4

Name and Signature of the Lab Administrator

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