IIRM JAIPUR CAMPUS

Student Application for Internet Access

Name of the Institute / College (in which enrolled)
Affix & Cross Sign
FMS-IRM SMPGC Scholar No.__________________
A Recent

Name of the Course (in which enrolled) Photograph

Name of the Applicant (exactly as it appears on the College/Institute Admission Form)

Mother’s Name:

Father’s Name:

Local Guardian’s Name:

Date of Birth: Gender : (Please Tick  )

Date Month Year Male Female

CONTACT DETAILS

CORRESPONDENCE ADDRESS (For all communication by the Institute)

Line 1__________________________________________________________________________________

Line 2_________________________________________________City/Town_______________________

Distt._____________________ State/Province____________________ Pin code___________________

Phone No. (With STD code)____________________________ Mobile No.________________________

E-mail address (Applicant)_______________________________________________________________

E-mail address (Parent/Guardian)_________________________________________________________

 DECLARATION BY THE APPLICANT

I,___________________________________S/D/o______________________________declare that :-

1. All the particulars given by me in this application form are true and correct to the best of my
knowledge.
2. I shall NOT :
 Violate copyright laws.
 Use other person’s User IDs, Passwords, Personal Identity or Email Addresses.
 Violate security systems which have been put into place to protect computers, file
servers, networks & users.
 Use internet access in any ways which wastes the internet bandwidth.
 Use internet services for non-educational purposes.
 Download illegal files, torrents, movies, music etc.
 Give my Username & Password to others for any kind of use.
3. I understand that in case of any violation of any of the internet usage rules & regulations, I
may be penalized/rusticated from the institute.
4. I understand that all my internet activities may be logged.
5. In case of any violation of any copyright laws, I shall be solely held responsible and may be
subjected to legal action. In such circumstances neither me nor my parents/guardians shall
claim any sort of damages from the institute and/or administration.
6. I understand that these rules & regulations are enforced for the safety of me and my peers &
thus they may be modified/amended as per the discretion of the administration without
any prior notice.

Place : Signature of Applicant

Date :

CHECKLIST OF ENCLOSURES
Tick () if
S.No. Description
Submitted
1. Two Passport Size Recent Color Photographs
2. Photocopy of Front of College/Institute ID Cards (Self Attested)

------------------------------------------------ -----------------------------------------------
OFFICE USE ONLY
Application verified by :

Name : ______________________________

Signature :

Date : ______________________