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INDIAN INSTITUTE OF INFORMATION TECHNOLOGY GUWAHATI
(APPLICATION FORM FOR IDENTITY CARD FOR STUDENTS)
To be filled in BLOCK LETTERS and send this form ( soft-copy in MS Word format only to the mail ID [email protected]
(write email subject as Roll No-Application for ID card)
FULL NAME: _______________________________________________________
PROGRAMME: B.Tech (Branch) Paste your passport
photograph
(Should be in formal attire)
ROLL NUMBER: _______________________________________________________ and attached the photo in
email attachment
DATE OF BIRTH: _______________________________________________________ File name: Roll No-Photo
Example: 2501xxx-Photo
BLOOD GROUP: ____ __________________________________________________
PRESENT ADDRES: (Students who are not residing at the institute hostel, must write his/her present address properly with the details
VILLAGE/LOCALITY, TOWN/CITY, STATE, PINCODE)
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
FATHER’S/GURDIAN’S NAME ____________________________________________
HOME/PERMANENT ADDRESS: (MUST WRITE AS: VILLAGE/LOCALITY, TOWN/CITY, STATE, PINCODE)
Emergency Contact No: ______________________________________________________________________
(In case of Emergency, to contact your Parents / Guardians)
Holder’s Contact No: ______________________________________________________
Holder’s EMAIL ID: ______________________________________________________
Paste your signature and
attached the photo/image
of the signature in the
email attachment
File name: Roll No-Sign
Example: 2501xxx-Sign
SIGNATURE
FOR OFFICE USE ONLY
Valid Up to: ___________________________
Issue No: _______________________________Issued By_________________________ Date:
__________________________
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(Rename the Application Form file as: Roll No-Application Example: 2501xxx-Application)
Page 2 of 2
