ANNEXURE- IV

Form for General Information for Identity Card/Library Card

1

(To be filled in Capital Letters)

Name of Student: NITISH KUMAR

2 Name of the Programme: PGDM Class Roll No 2015/…………………

3 (Office Use Only)

Male/Female : MALE

4 Father’s Name: SHRAVAN KUMAR

5 Mother’s Name: MANJU KUMAR

6 Father’s /Mother’s Occupation: SERVICE / HOUSEWIFE

7 Father’s Office Address: KRISHAK BHARATI COOPERATIVE LIMITED,

8

PO: KRIBHCO NAGAR, SURAT-394515, GUJARAT.

Address for Correspondence with Tel. No.: D 902, KRIBHCO TOWNSHIP

9

10 Blood Group: A(-ve)

11

12

13

Date of Birth(DD/MM/YY): 21/10/92

E-Mail ID: nitish.735@gmail.com

Student Mobile No.: 09428630904

Nearest Railway Station: SURAT

14 Nationality: INDIAN Religion: HINDU

(Candidate Signature)

Stamp Size

Photo

PO: KRIBHCO NAGAR, SURAT-394515, GUJARAT.

Tel: 0261-2802679 / Mob: 9925240223

Permanent Address: D 902, KRIBHCO TOWNSHIP

PO: KRIBHCO NAGAR, SURAT-394515, GUJARAT.

Tel: 0261-2802679 / Mob: 9925240223