The Secretary,
Alumni Association,IIT Kanpur

         Please Get My Life Membership Card made and update the following details in the database of the Alumni Association:

First Name:		Middle Name:		Last Name:

Roll No:

Degree    Select BT MSC2 MSC5 PHD MT DIIT MEM MPHIL MBA MDES MT(DUAL) MT-PHD(DUAL) MSC-PHD(DUAL)

Branch:    Select MME AE EE IME HSS NET CSE CE CHM MATSC MSP MDES ME MTH CHE STAT PHY LT LTP BSBE EEM ENV ECO

ConvoYear:

Any Other Degree from IITK:

Roll No:

Degree    Select BT MSC2 MSC5 PHD MT DIIT MEM MPHIL MBA MDES MT(DUAL) MT-PHD(DUAL) MSC-PHD(DUAL)

Branch:    Select MME AE EE IME HSS NET CSE CE CHM MATSC MSP MDES ME MTH CHE STAT PHY LT LTP BSBE EEM ENV ECO

ConvoYear:

Father's Name:

Date of Birth:

Gender: F M

Permanent Email ID (Not IITK Email ID):

Email ID:
Permanent Address:

City:

State:

Phone No:

Company Name:
Designation:

Office Address:

City:

State:

Country:

Office Fax:

Office Phone:

Address for correspondence:      Residence      Office

         I hereby consent to be a Lifemember of the Alumni Asscociation, Indian Institute of Technology Kanpur and authorize IITK to deduct a sum of Rs 1300.00(Rupees One thousand and three hundred only) from my caution money and to pay the same to IITK Alumni Association towards my "Lifemembership Fees" as a contribution to the corpus of the Association.

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