BITS Pilani, Dubai Campus He FRESH APPLICANT Academic Year - 2022-2023 Name: DEVANSH MITTAL Sex: (IF Nationality INDIAN ppNno W459S [92 Blood Group: Visa Status: BIFS/Others, Specify, Emergency Contact No & Name: 7415" 2916 14 DEEPAK Kump mr ——$— PARENT DETAILS LOCAL GUARDIAN DETAILS Name of the Parent_DEEPAK KUMAR MITTAL |Name of the Guardian Designation:_ FATE: Designation: Address D_54/S0 CopPostTE mAkuTi | |Address ShowRoom) RATH YATRA -MANMDoKY AWG LAOAD, mMAHMcOKLANT, VARANASI, 221010 | e (2912 S422 36 40094 Ph (Off): [CLUTH 1694 Ph (Res): Ga) F40400 1644 Mobile: Emai T. What is your Blood Group 7_BE 2. Are you suffering from any chronic disease? Ityes, details: = 3. Ate you under any regular medication? if yes, details 4. Are you allergic to any medicine? if yes, details Tam aware that any changes in the details provided above will be informed immediately to the Institute. Ihave read the following documents fully and | confirm full acceptance to the same. a) Terms & Conditions of Hostel Contract 1b) Anti-Ragging Undertaking request for providing hostel accommodation. Devart, Mittal ~ Feu Signature of Student Counter Signature of Parent The candidate is admitted to. and has paid all required fee. His! Her ID no. is Sr. Manager - Admissions Hostel Allotted Hostel Block: Signature of Hostel Warden. Signature of Chief Warden Date: