* These fields are mandatory

* Name :

* Date of Birth :

* Marital Status :

E-mail ID :

* Father's / Husband's Name :

* Father's / Husband's Occupation :

* Monthly income of Family / Yours :

* Permanent Address with Ph. No. :

Name of local guardian living at Gwalior :  

Address  of local guardian  with Ph. No. :

Name of College / Employer :

Course / Designation :

Principal / key person name  with Ph. No :

Right now residing at :

Reason of leaving the place :

Expected stay in Hostel :

Blood Group :

Name of Expected visitor (1)
with Phone No. & relationship :

Name of Expected visitor (2)
with Phone No. & relationship :

Name of Expected visitor (3)
with Phone No. & relationship :