INDIAN INSTITUTE OF TECHNOLOGY,BOMBAY

SECURITY SECTION

APPLICATION FOR FAMILY MEMBER'S IDENTITY CARD

(To be filled in by the employee )

EMPLOYEE CODE NO.

Name :
Designation: Deptt. :
E-Mail Address :
Tel.No. (Office): Tel.No. (Res.) :

Family Particulars

Sr. No. NAME (IN CAPITL LETTERS ONLY) DATE OF BIRTH RELATIONSHIP BLOOD GROUP
1
2
Photos of family members Specimen signatures of family members in black ink
1 2 1
2

Note :

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 :
Date :- Signature :-

VERIFICATION

( 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 From To

6. If Pmt. Date of retirement
Medical entitlement :
Mark (V) the applicable box below

For Employees

Free Medical facility
Only OPD facility
No Medical facility

Sl. No. not entitled for medical facility.

Any other remarks

Date :

A.R. / O.S.

(To be filled by Security Section only)

Employee Code Sr. No. Valid upto Date of Issue Signature Remarks