Date:

B.Tech Student

Please fill in CAPITAL letters only

Name in English (as per Matriculation Certificate):

Name in HINDI: --------------------------------------------------------------------------------------------------

Roll No. Programme

Contact email Other than IIT Mandi:

Father’s Name: Mother’s Name:

Father’s Phone No.: Mother’s Phone No.: _

Address for Communication (Other than IIT Mandi):

PIN CODE

DECLARATION/UNDERTAKING

I Certify/Undertake that:

1. The spelling of my name in English is correct (as per records) and shall be considered for printing in
my degree.
2. The spelling in Hindi is correct and shall be considered for printing in my degree.
3. After graduation, all the correspondence from institute shall be done on the address provided in this
form. In case of any change, I will intimate the same to the institute.
4. I will not hold the Academic office/Institute responsible for any loss/damage/delay of document due to
postage/in transit.

Date:

Signature of the Student

Mob No.