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Student Pre-Arrival Form

Details to be submitted by Students while re-entering NIT Silchar campus
SLNo Details
Name of the Student with contact SHBAM UMAR SiNaU
noand email id 90852694s0
Course /Dept. BACHELSR OF TEHNoLOGY
ME CHNTCAA ENAT NEERTNA
Scholar No Q01604
Purpose of reporting8
ASME IAM3D, 202
Full dose of COVID-19
Vaccination certificate (Yes/No) NES
RTPCR report (Yes/No) ES
Declaration/undertaking YES
submitted (Yes/No)_
Mess advance paid and proof
submitted (Yes/No)
10 ArogyaSetu Registered Mobile 0856UOO
No
11 Current hostel address

Arriving from city/town and full BUTTONPORE TE .0.-NUNAPANI,

2 address
CACHR, ASSAM-844.
Date and time of Departure & 0-104 2022 (01 00 pm)-O4/o 1a0Ra
13
arrival at NITS (0200 Pm
Contact number of Parents/ILocal
14 94356A6960
guardian/ Relatives
Train Noo Name Coach/Seat

Flight No Carrier Seat no

15 Mode of transport
Bus No Bus Namne Seat No

Car/Taxi No Service
PUBLSC TRMNSPORT
History of Fever, Cough,
shortness of breath
NO
16
Were you tested for COVID? NO
 Are you 1st contact of a COVID
NO
positive patient?

Any other information or travel

7
history for past 6 months

Have you downloaded

18 NES
AarogyaSetu app?

Marked safe in ArogyaSetu app: YES

19
(Yes/No)

Signature & Date: Shutnam kuman Sing

CO/o4l2022)