Pass No. :
Date :

APPLICATION FOR TEMPORARY ENTYR PERMIT

PART-I TO BE FILLED BY APPLICANT

TYPE OF PASS : VENDOR SUPPLIER MORNING WALK
MAID SERVANT CONTRACTOR SHOPKEEPER
IN CAMPUS

FULL NAME :
AGE :
ADDRESS :
WORK NATURE :
IN CAMPUS :
PLACE OF WORK :
Time To Be Permitted :
REMARKS :
SPECIMEN SIGN. :

Left Thumb Impression Right Thumb Impression
THUMB IMPRESSION

UNDERTAKING

  1. I will not enter any residential quarters or Hostel rooms until & unless called by the resident.
  2. I will not disturb the residents either by knocking the door or ringing the doorbell.
  3. I will restrict myself only to specified area mentioned in entry pass.
  4. I shall surrender the pass on demand by the security.
  5. I will enclose two photos of 4cm x 2cm along with the application form.
Photo
Signature : ____________________



PART-II TO BE FILLED BY EMPLOYEE RECOMENDING PASS

I personally know Shri./Smt. for the last years and undertake the responsibility of the conduct and behaviour of the above person within the campus.

Signature :
Name :
Designation :
Adddress :
Stamp

PART-III TO BE FILLED BY OFFICIAL / EMPLOYEE / RESIDENT RECEIVING THE MATERIALS

The above mentioned person is required to visit (place) for the supply of materials regularly.

Signature :
Name :
Designation :
Adddress :
Stamp

PART IV TO BE FILLED BY E.E / A.E RESPONSIBLE FOR WORK IN CASE OF CONTRACTOR

The above mentioned contractor has been awarded the job vide work order no. and the period of
contract is upto . He may issued with a pass for the above mentioned period.

E.E / A.E.


FOR SHOPKEEPERS INSIDE THE CAMPUS ONLY

PART V TO BE FILLED BY ESTATE OFFICER FOR SHOPKEEPER INSIDE THE CAMPUS

'

The shop inside the IIT Campus has been given on contract upto .
He/she may be issued with pass for the above mentioned period.

Estate Officer