Application No.: 15


PLEASE PROVIDE THE FOLLOWING DETAILS :

PERSONAL INFORMATION

COURSE APPLIED FOR :
NAME (SUR NAME FOLLWED BY GIVEN NAME) :
POSTAL ADDRESS (INCLUDING THE PIN CODE) :
PERMANENT ADDRESS (INCLUDING THE PIN CODE) :
DATE OF BIRTH : eg:17/04/2000
GENDER : MALE FEMALE
NATIONALITY :
RELIGION :
TELEPHONE NO WITH AREA CODE :
CELL PHONE NO :
PAN CARD No :
Adhar No :
DRIVING LICENSE NO :
Voter's ID No :

ADDITIONAL INFORMATION

NAME OF THE PARENT/GUARDIAN: :
POSTAL ADDRESS OF THE PARENT/GUARDIAN :
IN CASE OF GUARDIAN PLEASE INDICATE THE RELATIONSHIP TO THE APPLICANT :
PHONE NUMBER OF THE PARENT/GUARDIAN :
CELL NUMBER OF THE PARENT/GUARDIAN :
IF PARENT/GUARDIAN IS EMPLOYED, PROVIDE DETAILS OF HIS/HER EMPLOYMENT :
PLEASE INDICATE WHETHER YOU BELONG TO SPECIAL CATEGORY : a.SCHEDUELED CASTE
b.SCHEDUELED TRIBE
c. OTHER BACKWARD CLASSES(INDICATE SPECIFICALLY)

EDUCATIONAL BACKGROUND :

Name of the college and location
(from the most recent)
Period
(From - To)
Course Major subjects studied Class secured Percentage

WORK EXPERIENCE:(Most Recent First)

Job Title Company From To
AWARDS, MERIT CERTIFICATES, ACHIEVEMENT CERTIFICATES, IF ANY :
HOW DID YOU COME TO KNOW ABOUT RIMSR, AND THE COURSES OFFERED? :

PLEASE PROVIDE THE FOLLOWING DETAILS (FOR FOREIGN NATIONAL ONLY)

Pass-Port No :
Place of Issue :
Date of Issue : eg:17/04/2000
Date of Expiry: : eg:17/04/2000

PLEASE PROVIDE THE VISA PARTICULARS:

Date of Issue of Indian Visa: : eg:17/04/2000
Date of Expiry : eg:17/04/2000
Type of Visa :
Visa Number :
Place of Issue :

DECLARATION

I do hereby declare that I will abide by the rules, regulations and orders framed or passed by RIMSR from time to time. The information given by me in the application is true to the best of my knowledge and belief. I understandthat I will be held responsible if any incorrect or wrong information is given here, and in which case my admission is liable to be cancelled automatically. In such a case the decision of the Director, RIMSR is final and binding.


Upload Photograph   :

Upload SSLC Mark Sheet:

Upload Degree Certificate: (Student pursuing a degree program may upload latest marks card)

Signature of Applicant:   

Place   :

Date   :eg:17/04/2000

Enter Verification Code:


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