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INDIAN INSTITUTE OF TECHNOLOGY, ROORKEE

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REGISTRATION FORM

Regis No. Dated : ______________

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PERSONAL INFORMATION

Title: Mr. Ms. Dr. Prof.

Name: (Last Name, First Name, Middle Name)

Department:

Nationality :

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CATEGORY

STAFF :

Faculty Officer Scientist Admin

NON-TEACHING STAFF :

Tech. Minst.

STUDENT:
Under Graduate Post Gradauate
(M.Tech/M.E./M.Sc./M.Phil/MBA/MCA)
RESEARCH :

Fellow A/B/C Research Assoc. Research Scholar Others

Enrollment No. Year : I / II / III / IV / V

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User Name (Two Choices)

Password (It can be changed after the opening of account)

PAYMENT PARTICULARS
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Paid for Period to

Receipt No. Dated

( MM/DD/YYYY )

( Signature of User )

(Signature of Head of Department )

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INDIAN INSTITUTE OF TECHNOLOGY, ROORKEE

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OFFICE RECORD

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(To be filled by user)

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Password (It can be changed after the opening of account)

ID allotted for the Period to

Coordinator

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USER RECORD

Regis No. Dated : _______________

Name: (Last Name, First Name, Middle Name)

(To be filled by user)

E-mail ID : @ i i t r . e r n e t . i n
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Password (It can be changed after the opening of account)

ID allotted for the Period to

Coordinator