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HIMALAYAN MOUNTAINEERING INSTITUTE
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1. Name............................................................................................................................................. (IN BLOCK CAPITALS) 2. Permanent Address ........................................................................................................................ ..................................................................................................................................................... ..................................................................................................................................................... ..................................................................................................................................................... ...........................................................................................................Pin Code............................. 3. Date of Birth ...................................Age on the date of application..................................................... 4. Serial no.of the course to be attained- BASIC/ADVANCE/ADVENTURE COURSE (Tick the correct one) Ser No............................................. 5. Full Course Fee Rs. enclosed by Draft No........................................ Date : ....................................... 6. Academic Qualification..................................................................................................................... Any special qualification or hobbies connected with mountaineering including courses if any, attended earlier (a)................................................................................................................................................... (b)................................................................................................................................................... 7. Next of Kin(in the event of any eventually)with address & Telephone no. (if any)...................................... ....................................................................................................................................................... ....................................................................................................................................................... 8. In case of any injury etc.that may sustainduring the period of training.I will not hold HMI responsible for the same.I want to undertake the course as per my own will. The above entries have been made by me and are true and correct. |
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Date................................
_____________________________ (Signature of the applicant) Guardian (in case of minor) |
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Nationality........................................................................................................................................ (in case of private candidate it must be certified by a Sub-Divisional Magistrate / Gazetted Officer). Certified that I know the applicant and confirm that he/she is an Indian National. Date ............................. _____________________________ (Signature) Place................................ Seal Designation........................... |
Please enclose a demand draft of Rs.25/- and a medical certificate along with this certificate.
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