HI

MALAYANMOUNTAI
NEERI
NG I
NSTI
TUTE
JAWAHARPARBAT,DARJEELI
NG 734101
AFFI
X
PHOTO

APPLI
CATI
ONFORM

1. Name ..
(IN BLOCK CAPITALS)
2.

Permanent Address .
.
.
Phone no. .. Pin code ..

3.

Date of Birth Age on the date of application .

4.

Serial No. of the Course to be attended

BASIC / ADVANCE / MOI / ADVENTURE COURSE (Tick the correct one) Ser No )

5.

Full Course Fee Rs enclosed by Draft No .. Dt .

6.

Academic Qualification ..
Any special qualification or hobbies connected with mountaineering including courses, if any, attended
earlier.
(a) ...
(b) ...

7.

Next of Kin with address & Telephone / if any.

..
..

8.

In case of any injury etc, that may sustain during the period of training. I will not hold HMI responsible
for the same. I want to undertake the course as per my own will.
The above entries have been made by me and are true and correct.

Date..

_______________________
Signature of the applicant
Guardian ( in case of minor )

Nationality .
( in case of private candidate it must be certified by a Sub-Divisional Magistrate / Gazetted Officer )
Certified that I know the applicant and confirm that he/she is an Indian National.

Date...

________________
Signature

Place..

Seal

Designation.....................