INDIAN INSTITUTE OF TECHNOLOGY,BOMBAY

SECURITY SECTION

APPLICATION FOR EMPLOYEE'S IDENTITY CARD

(To be filled in by the employee )

EMPLOYEE CODE NO.

Full Name :
First name Middle Name Surname
Name you would prefer to get printed on identity card:
Designation: Deptt. :
E-Mail Address :
Date of Birth: Blood Group :
Tel.No. (Office): Tel.No. (Res.) :
Local Residential Address :
Permanent Residential Address :
Emergency contact :
Date :- Signature :-

Employee's Photo Specimen Signature in Black Ink.

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/-

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

Date :

A.R. / O.S.

(To be filled by Security Section only)

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