HIMT COLLEGE

(APPROVED BY D.G. SHIPPING, GOVT. OF INDIA)

Affix your recent Passport Size Attested Coloured Photograph

55, East Coast Road, 72B, Arambakkam Village, Vengambakkam Junction, Kalpakkam - 603 102 E-mail:admin@himtmarine.com website: www.himtmarine.com
APPLICATION FORM FOR ADMISSION Application No : Course Applied for: Academic Year:

1 2 3 4

Name of the Applicant (In Block Letters as per 10 th Std. Cert.) : Date of Birth Place of Birth Present Address: : : : : Relationship: Tel. No. : STD Code: Age: Years: Months:

Permanent Address

: : Tel. No.: STD Code :

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Blood Group Father's Name Father's Occupation Mother's Name Nationality : : :

11. Details of Educational Qualification From X standard onwards S.N Name of the Qualifying Exam : : : : : Year of Passing Board % obtained

12 13

Extra Curricular Activities Identification Marks

: :

N.C.C 1. 2.

N.S.S

Scout

Others

JOINT DECLARATION BY THE APPLICANT AND PARENT / GUARDIAN

We hereby declare that all the information furnished in this application is true and correct to the best of our knowledge and belief. The original Certificates will be produced for verification at the time of admission. In the event of any information furnished by us is found to be incorrect or false, we agree to rejection / termination of the candidature / admission and forgo any claim whatsoever. We understand that filling up this application form does not guarantee the confirmation of the seat at HIMT. If admitted, I ____________________________________________ hereby indemnify the HINDUSTAN INSTITUTE OF MARITIME TRAINING and Faculty, Instructors and staff of HINDUSTAN INSTITUTE OF MARITIME TRAINING from any claim what so ever arising out of personal injury to me, or my death due to any accident during the period of training and also I undertake to attend all classes regularly and punctually and to comply with all regulations of the institute.
Date : . Place :
.

Signature of the Applicant : ________________________

Signature of the Parent / Guardian :__________________

Note : Kindly submit 2 recent photographs along with application. Enclosures: (Please mention Documents you have enclosed) 1. 2. 3. 4. FOR OFFICE USE ONLY (THIS SHOULD NOT BE FILLED BY APPLICANT) Batch No. ______________Date___________ Roll No. : ________________________ Eligibility Scrutinized By: ________________________ (As per DGS Guidelines) Section Notice Sent On: Date of Reporting:
Age: Mark sheet Verified By: Medical Test Report: Colour Blindness:

Selected

Rejected

Waitlisted

Payment Details Fees Receipt. No__________ Date____________ Amt___________________