IITR ALUMNI ASSOCIATION, IIT ROORKEE

FORM FOR ISSUE OF LIFE MEMBERSHIP CARD FOR LIFE MEMBERS

Honorary Secretary Phone No. : 01332-285630

IITR Alumni Association FAX No. : 01332-285630
Main Administrative Building E-mail : iitraa@gmail.com
Indian Institute of Technology Roorkee Website : http://www.iitraa.in
ROORKEE 247 667
Uttarakhand, India
Note Please use capital letters & furnish complete information

Please attach your

recent passport size
1. Name in FULL WASEEM AHMAD SHAKEEL
____________ _________________ ________________ Photograph OR
(Surname) Middle name (First name) its soft/ scanned
(As recorded on Degree Certificate - please attach a photocopy ) copy may be
2. mailed to
27-08-1989 membershipcard.iitraa
Date of Birth (DD/MM/YYYY) ___________________________
@gmail.com
3. Name of FIRST DEGREE & YEAR from IITR (formerly UOR):
M TECH. STRUCTURAL DYNAMICS 2013
Degree __________________Branch _______________________Year ____________
4. CED IIT ROORKEE
Name of Department presently serving - ____________

RESEARCH SCHOLAR, DEPARTMENT OF CIVIL ENGINEERING,

5. Present ____________________________________________________
designation & IIT ROORKEE
____________________________________________________
office address
ROORKEE 247667
__________________City _________________PIN __________

F-63, AZAD BHAWAN, IIT ROORKEE, ROORKEE

6. Present residential ____________________________________________________
address
ROORKEE 247667
______________________City ______________ PIN _________
9758461370
Tel. with STD code: ___________________(O),________________(R),__________________Mobile
7.

E-mail : shakeelwaseem@ymail.com, shakeeliitr@gmail.com

___________________________

8. Address for correspondence Office Residence

Place:

Dated:
Specimen Signatures (in Black ink)

FOR OFFICE USE ONLY

Life Membership No. allotted Card No. Date of issue

Dealing Assistant Honorary Secretary