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Tele

: 22123, 24663

Appx.'A' (Refers to Para 19)

Std Code

: 01374

Grams

: NIMOUNT

ISD Code

: 91 1374 22123

Fax

: (01374)-23344

e-mail

: nimutk2004@gmail.com

NEHRU INSTITUTE OF MOUNTAINEERING

Uttarkashi - 249193 INDIA
(TO BE FILLED OR TYPED IN BLOCK LETTERS INCOMPLETE FORMS WILL NOT BE ACCEPTED)

Affix
Photograph
here
(1)

Affix
Photograph
here
(2)

1. Name____________________________________________________________________________________________________
2. Date of Birth______________(in words) ______________________________________________________________________
3. Occupation_______________________________________________________________________________________________
4. Permanent Address________________________________________________________________________________________
_________________________________________________________________________ Pin Code ______________________
Telephone with STD Code _________________________________ E-mail __________________________________________
5. Telephone with address and next of kin, Parent/Guardian (in the event of an accident)
Name___________________________________________________________________________________________________
Address__________________________________________________________________________________________________
_______________________________________________ Pin Code ________________ Telephone ______________________
STD Code ____________________ Fax ________________________ E-mail ________________________________________
6. Course Serial No. (a)_________________ (1st option) Commencing on ______________
(b)_________________ (1st option) Commencing on ______________
7. Course to be attended viz Basic/Advance/Adventure/Search & Rescue/ Method of Instruction/ Mountain Guide.
8. Details of Basic/Advance course previously attended with Grading_______________ (Attach a copy of Basic course
certificate for Advance course. Attach Advance course certificate for S&R /Guide and Courses).
9. Vegetarian or Non-Vegetarian. ______________________________________________
10. Training fee Rs ____________ is enclosed vide Bank Draft No. _____________________dated
________________________________________ (forward SBI Bank Draft only).
I have read the rules and regulations of NEHRU INSTITUTE OF MOUNTAINEERING, UTTARKASHI relating to the courses of
training in Mountaineering/Adventure/Search & Rescue/ Method of Instruction/ Mountain Guide and have fully understood
the meaning and significance of the same. The above entries have been made by me and they are true and correct.
Date________________

Signature of applicant_________________________

11. Nationality _________________________ ( in case of private candidate must be certified by Sub-Divisional Magistrate or
a Gazetted Officer).
Certified that I Know the applicant and confirm that he is an Indian National
Date________________________

Signature of Gazetted Officer___________________

Place_______________________

(with seal)

12. I hereby certify that all the entries are correct in every respect. In case of deaths, accident or injury of any form, the
Institute or any of its staff will not be held in any manner wholly or partially responsible.
Signature _____________________
Date 1. _________________

1. Applicant ____________________

Date 2. _________________

2. Parent/Guardian_______________
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CONFIRMATION (OFFICE COPY)

Latest Postal Address on which Confirmation will

be dispatched

(To be filled by candidate in Block Letters)

(To be filled by candidate in Block-Letters)
Name_____________________
Postal Address: ____________________________
__________________________________________
Pin______________
(For official use only)
Seat Confirmed / Provisionally reserved in Course Ser
No.___________________________________

To,
____________________________
____________________________
____________________________
____________________________
____________________________
____________________________
____________________________
____________________________

Duration____________________________________
Date of arrival at NIM________________________
Date of departure from NIM____________________
Fee Details: DD No_____________Dated_________
Amount____________is here by acknowledged.

Requirement( if any)
(a)_____________________
(b)______________________
Please submit the above within one month for final
confirmation.
Dated:
No. Trig:

OIC Training
NIM, Uttarkashi

If undelivered, please return to:Nehru Institute of Mountaineering,

Uttarkashi(UA)-249193
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