Application Form

* If Applicant can bear the expenses in his / her own capacity to meet all charges will require to give his / her own bank details along with one guarantor

* If Applicant is incapable to bear his / her own expenses, he / she will require the bank details of 1st & 2nd guarantors

Name of the Applicant:

Profile Picture:

Gender: Male Female

Date of Birth

Marital Status: Bachelor Married Widow/Widower Divorcee Separated

Faith:

Mobile:

Email:

Address of Applicant:

Health Insurance Details

Do the applicant has health insurance? yes No

Name of Insurance Company:

Insurance No:

If the applicant is undergoing any medical treatment kindly give the details:

Type of Agreement: Select Long Term Agreement One Year Agreement Short Term Agreement Life Long Agreement

Schedule Room Opted: Select Double Occupancy (AC) Double Occupancy (Non-AC) Single Room (AC) Single Room (Non- AC)

Mode of Payment: Select Cash Net Banking Or Account Transfer DD Pay Order

Guarantors Details:

Guarantor Name 1:

Guarantor Name 2:

Address:

Mobile:

Email:

Relationship with Applicant:

Occupation:

Annual Income:

Licensee fees & other Expenses to be borne by: Select Applicant Guarantor 3rd Party

Bank Details of Remitter:

Bank Name:

Branch Name:

Account Number:

Name as per Bank A/c:

IFSC Code:

Address of the Account Holder:

Mobile:

Email:

Guardian Details:

Name of Local Guardian:

Mobile:

Email:

Address of Local Guardian: