INDIAN INSTITUTE OF TECHNOLOGY,BOMBAY
APPLICATION FOR FAMILY MEMBER'S IDENTITY CARD
(To be filled in by the employee )
EMPLOYEE CODE NO.
E-Mail Address :
Tel.No. (Res.) :
NAME (IN CAPITL LETTERS ONLY)
DATE OF BIRTH
Photos of family members
Specimen signatures of family members in black ink
1) Employess are requested to submit the form to Security Office at Main Bldg. after getting it verified by th e Admn./Rect./Project Section.
2) Fill up the information neatly since the card cannot be corrected after it is printed
3) Employees are requested to submit two recent color photographs of passport sizw with blue background (front face, with both ears visible) of self along with the application
4) Fine for loss of Employees Identity Card is Rs. 300/-
Local Residential Address :
( To be certified by Admn./Rect./Project Section only)
Please (v) wherever applicable
Date of joining :
1. Status of appointment
Ty. / Pmt.
2. Institute Employee
3. Project employee
4. MHRD Project employee
5. Ty.period of appointment
6. If Pmt. Date of retirement
Medical entitlement :
Mark (V) the applicable box below
Free Medical facility
Only OPD facility
No Medical facility
not entitled for medical facility.
Any other remarks
A.R. / O.S.
(To be filled by Security Section only)
Date of Issue