HIMALAYAN MOUNTAINEERING INSTITUTE

JAWAHAR PARBAT, DARJEELING – 734101

website: www.hmidarjeeling.com Tele: 0354-2254087 AFFIX
email:hmidarj@gmail.com PHOTO
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MAY (YOU) CLIMB FROM PEAK TO PEAK
APPLICATION FORM
INCOMPLETE FORMS WILL NOT BE ACCEPTED
(Details including email id to be filled/typed in CAPITALS only)

1. Name ……………………………………………………………………………………………………………………………………………………………………….

2. Permanent Address ………………………………………………………………………………………………………………………………………………..

……………………………………………………………………………………………………………… Pin code …………………
(Please enclose address proof)

Phone no…………………………………………………………………………Email id…………………………………………………………………………..(CAPITALS only)

3. Next of Kin (in the event of any eventually) with address & Telephone / if any.

Name……………………………………………………………………………………………………………………………Relationship…….……………….

Address ………………………………………………………………………………………………………………………………………………………………….

Pin Code ……………….……………Mobile No…………….…………………..….Email ID……………………………………………………………

4. Date of Birth …………………………… Age on the date of application ………………………………….

5. Shoe Size in UK Pattern: 6, 7, 8, 9, 10, 11, 12 Jacket Size: S, M, L, XL, XXL (Circle correct size)

6. Dietary Details :- Veg / Non Veg/ Egg Veg (Strike off incorrect options)

7. Academic Qualification………………………………………….………….…Occupation…………………..…………………………………………

Monthly Income (If student please mention Parents’ Income) ……………………………………………

8. Course to be attended BASIC / ADVANCE / MOI / ADVENTURE COURSE/SPECIAL COURSE (Strike off incorrect options)

Course Ser. No. (a) ………………………………..(1st option) commencing on ……………………………..

(b)……………………………… (2nd option) commencing on……………………………….

(c)……………………………….. (3rd option) commencing on ……………………….......

(Reporting time & date: 1400-1700 hrs one day prior to course commencement date, course participants won’t be allowed entry
into HMI premise before & after the reporting time, LATE ARRIVALS EVEN BY ONE DAY WILL NOT BE PERMITTED TO JOIN
THE COURSE.)
Details of Basic/ Advance course previously attended with Grading…………………..
(Attach a copy of Basic Course Certificate for Advance Course. Attach Advance course certificate for MOI course)

9. Any special qualification or hobbies connected with mountaineering including courses if any, attended earlier.

(a) ……………………………………………………………………………………………………………………………………………………………………………………..

(b) ……………………………………………………………………..………………………………………………………………………………………………….………...

10. Course Fee Rs _____________________ ; Special Course fee_____________________

Receipt / UTR No & Date ………………………….............................................................................................................

(Attach printout/receipt for online/ NEFT/direct deposit in HMI account. Write your name & course serial no. on the reverse
side of proof of payment. Demand Draft/ Cheque / Cash payment NOT acceptable.)

11. Bank Account No………………………………………………. Bank Name and Branch………………………………………………………….

IFS Code……………………………………………………………. (For refund of course fee if required)

*Criteria for refund of course Fee is given in the Training Programme available on www.hmidarjeeling.com.
12. Nationality …………………………………………………….. (Foreigners to attach copy of passport)

13 I hereby certify that all the entries are correct in every respect. In case of any injury, loss of limb, sickness, heart attack or
death etc. that I may sustain during the period of training, neither the Institute or any of its staff be held wholly or partially
responsible nor any compensation be claimed from the Institute or Government.I want to undertake the course as per my own will.

Date…………………….. ………………………………………………
Signature of the applicant
Place……………………. Guardian (in case of minor)