FACILITIES

ANTI RAGGING UNDERTAKING BY STUDENTS AND PARENTS/GUARDIANS

Fields marked with red *  are compulsory.

Personal Details
	Student's Family Name  *
	Student's Middle Name
	Student's First Name  *
	Gender*	MaleFemale
	Nationality  *
	Student's Mobile Number*
	Student’s friends Mobile number in case of an emergency  *
	Landline Number
	Student's Email ID  *
	Confirm student's Email ID  *
	Permanent Address 1  *
	Address 2 *
	City*
	State  *

Parent/Guardian Details
	Parent/Guardian’s name  *
	Parent/Guardian Address 1 *
	Parent/Guardian Address 2
	City  *
	State *
	Residence Phone No *
	Mobile No of Parent/Guardian  *
	Parent/Guardian’s Email ID *

College Details
	State in which the College is  *
	Is it a Professional College or a General College *	Engineering Pharmacy Degree + 3 + 2 Others
	Student's First Name  *
	Name of the College *
	Name of Affiliated University   *
	It is Deemed University *	YesNo
	Director/Principal Family Name  *
	Director/Principal First Name *
	Director/principal Gender   *	MaleFemale
	College Phone No. 1  *
	College Phone No. 2
	Nearest Police station Name and Address *

Course Details
	Under Graduate or Post Graduate    *	Under Graduate Diploma Post Graduate Diploma Under Graduate Degree + 3 + 2 Others
	Name of the Course *
	Your Registration/Enrolment  Number
	How many students are in your Class *
	Year of Study  *