| 1. |
Name
(IN BLOCK CAPITALS) : |
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| 2. |
Permanent
Address : |
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Pin
Code : |
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| 3. |
Date
of Birth : Age
as on the date of application : |
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| 4. |
Serial
No. of the course to be attained (write below) |
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BASIC/ADVANCE/MOI/ADVENTURE
COURSE (Tick the correct one) |
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Serial
No. : |
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| 5. |
Full
Course Fee Rs..................................enclosed by Draft No.....................................Date:.................................. |
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| 6. |
Academic
Qualification : |
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Any
special qualification or hobbies connected with mountaineering including
courses if any, attended earlier. |
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a) |
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b) |
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| 7. |
Next
of kin (in the event of any eventually) with address & Telephone (if
any) : |
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| 8. |
In
case of any injury etc. that may sustain during the period of training,
I will not hold HMI responsible for the same. I want to undertake the course
as per my own will. |
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Date :........................................................... |
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(Signature
of the applicant) |
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Guardian
(in case of minor) |
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Nationality
: |
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(in case
of Private candidate it must be certified by a Sub-Divisional Magistrate
/ Gazetted Officer. |
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| Certified
that I know the applicant and confirm that he/she is an Indian National. |
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Date :........................................................... |
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Place :................................
Seal : |
Designation
: |
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IMPORTANT
:
Along with the Full Course Fee add Rs. 50 (Two Dollars incase of Foreign
Nationals) in favour of Principal, Himalayan Mountaineering Institute, without
which it will be rejected. **Read the online
instructions
before filling up the form.
Do not change or edit anything on this form. |
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