NATIONAL INSTITUTE OF TECHNOLOGY PATNA Ashok Raj Path, PATNA 800 005 (Bihar), India
(SECURITY SECTION)
APPLICATION FOR ISSUANCE OF TEMPORARY SECURITY PASS
Nature & Place of work: ………..
PARTICULARS OF PERSON FOR WHOM PASS IS TO BE ISSUED: Photo
1. Name : ………...
2. Father’s/Husband’s Name : ………...
3. Date of Birth/Age : ………. 4. Sex (M/F): ……….
5. Nationality : ………...
6. Contact No. : ………...
7. In case of emergency; whom
to contact with mobile number : ………...
8. Residential Address (Attach proof) : ………...
9. VIM (Visible Identification Marks) : ………...
10. Duration/Stay of work :Time from …….……...…..…….. to ……….….…..………
Declaration (i) : I hereby declare that the details furnished above are true and correct to the best of my knowledge and belief and I undertake to inform you of any changes therein, immediately.
(ii) : In case of any accident /miss happenings etc., NIT Patna administration will not be liable for the same inside the campus.
(Signature of the applicant) ______________________________________________________________________________
RECCOMENDATION
1. I endorse the information given above by the applicant and recommend the candidature of Shri/Smt.
………. For issuance of temporary security pass for the nature and place of job mentioned above.
2. I take the responsibility of his/her discipline, good conduct and honesty in the campus in consonance with the orders and practices of the Institute.
Date: Name & Signature of person recommending Temporary Pass Sl. No. ……… Dated ……… Issued
Sign. of S.O.
Note: Attach two Nos. of passport size & one stamp size photographs with this application form.
