GITAM SCHOOL OF TECHNOLOGY,

BENGALURU CAMPUS
NH-207, Nagadenahalli, Doddaballapur Taluk, Bengaluru Rural Dist -561203

Membership Number:

Email: director_blrcampus@gitam.edu Phone: 080-28098000

Website: www.gitam.edu Fax: 080-28098000

Alumni Membership Form

Name: Date of Birth:
Marital Status: Single/Married Gender: (M / F) Blood Group:
Qualification: Branch:
Email: Tele/Mobile:
Address for Communication

Residence Office Permanent

Year of passing from GST, GITAM (Deemed to be University) :

Present Designation:
Area of Interest:
Awards / Honors Received:
Any Other Information you wish to mention:

Signature of the Applicant

Received a sum of Rs.500 (Rupees Five hundred only) towards membership fee.

Head of the Department