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The document is an application form for the Diploma in Nautical Science (DNS) course for the intake of August 2025, submitted by Prabhat Dubey. It includes personal details, academic qualifications, and a declaration of the accuracy of the information provided. The application fee and course fee have not been paid yet, and the applicant acknowledges the consequences of providing false information.

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prabhatdubey75054
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7 views

Doc992

The document is an application form for the Diploma in Nautical Science (DNS) course for the intake of August 2025, submitted by Prabhat Dubey. It includes personal details, academic qualifications, and a declaration of the accuracy of the information provided. The application fee and course fee have not been paid yet, and the applicant acknowledges the consequences of providing false information.

Uploaded by

prabhatdubey75054
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
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APPLICATION FORM

Course: Diploma in Nautical Science (DNS)


Intake : IMEC DNS (AUG 2025)
Application Form Number : 705681

PERSONAL DETAILS

Full Name (As per 10th Marksheet): Prabhat Dubey


Date of Birth : 10 December 2007 Email : [email protected]
Mobile : 7505407566 Blood Group : -
Gender : - Nationality : -
Height ( >156 cm only ) : - Weight ( >46 kg only ) : -
Identification Marks : -

PARENT'S DETAILS

Father/ Mother/ Guardian's Name : -


Father/ Mother/ Guardian's Mobile Number : -
Father/ Mother/ Guardian's Email ID : -
Father/ Mother/ Guardian's Occupation : - Father/ Mother/ Guardian's Annual Income : -

ADDRESS
Address Line 1 : -
City : - District : -
State : - Country : -
Pincode : -

ACADEMIC QUALIFICATION DETAILS AND DOCUMENTS

10th Standard Academic Details

Institute Name : -
Board : - Year of Passing : -
English Marks : - Marks Scheme : -
Obtained Percentage/CGPA/Grade : - What is the status of your PUC / XII / Equivalent /
Diploma? : -

12th Standard / Diploma Academic Details

Institute Name : -
Board : - Year of Passing: -
What is the status of your Results? : - Marks Scheme : -
English Marks : - PCM Marks : -
Obtained Percentage/CGPA/Grade : -

Graduation / Diploma Academic Details


Institue Name : -
University Name : - Degree : -
Year of Passing : - Result Status ? : -
Marking Scheme : - Obtained Percentage / CGPA / Grade : -

UPLOAD SECTION

Upload Photos : No Upload Your 10th Marksheet (PDF) : No


Upload Your 12th Marksheet (PDF) : No Upload Your Passport Copy (Front page, back page &
Stamped page)(PDF) : No
Upload Your University Marksheet (Consolidated or
Semester-wise consolidated into a single
document)(PDF) : No

DECLARATION

DECLARATION BY CANDIDATE

I declare that all information provided in this form, is true and complete in all respect : No

I fully understand that any misrepresentation or omission of information may be considered sufficient for
withdrawal of the offer and dismissal from the course at any time : No

I confirm that the information as set out in this application were provided by me and that the said information
is true and correct : No

I understand that I may be subject to prosecution if I have provided any information, which is false in any
materia particular or is misleading by reason of the omission of any material particular : No

I have not submitted any false statement or submitted any document which I know to be false in order to
obtain the admission at HIMT : No

I will be admitted for the Course at HIMT College if I am eligible for the course as per D.G.Shipping
Guidelines. I also understand that HIMT College will only provide placement assistance and is not
responsible for guaranteeing Placement in any of the companies. The placements are dependent entirely on
the shipping companies interviewing me, their eligibility criteria, and my performance in the interview : No

I will not hold HIMT College responsible for not getting placed in any company : No

JOINT DECLARATION BY THE STUDENT AND PARENT / GUARDIAN

We hereby declare that all the information furnished in this application is true and correct to the best of our
knowledge and belief. The original Certificates will be produced for verification at the time of admission. In
the event of any information furnished by us is found to be incorrect or false, we agree to rejection /
termination of the candidature / admission and forgo any claim whatsoever : No

We understand that filling up this application form does not guarantee the confirmation of the seat at HIMT. If
admitted to this course, I also to abide by the rules and regulations of HIMT. I do agree to abide by the Anti
Ragging Regulations, as directed by the Honourable Supreme Court of India : No

I have read the T&C : No

I hereby agree that I confirm myselves fit with reference to Physical, Medical and Eyesight standards (As per
DGS orders) and color blindness : No
I hereby agree to submit Valid passport at the time of admission. Please note that the name on the passport
will be the standard use for all certification purpose as per DG Shipping orders : No

APPLICATION FEE PAYMENT DETAILS

Course Name : Diploma in Nautical Science (DNS)


Fees Amount : 99
Paid Status : Not Paid

COURSE FEE PAYMENT DETAILS

Course Fees Amount : 495000


Paid Status : Not Paid

I certify that the information submitted by me in support of this application, is true to the best of my
knowledge and belief. I understand that in the event of any information being found false or incorrect, my
admission is liable to be rejected / cancelled at any stage of the program. I undertake to abide by the
disciplinary rules and regulations of HIMT.

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