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Application Form For Wi-Fi Connection

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|| अंतरी पेटवू ज्ञानज्योत ||

उत्तर महाराष्ट्र ववद्यापीठ


पत्रपेटी क्र.८०,उमववनगर, जळगाव

Application form for Availing Wi-Fi Internet Connectivity on NMU Campus

To,
Prof. Dr. B. V. Pawar,
Director School of Computer Sciences,
North Maharashtra University Jalgaon.
Sir, I hereby request you to kindly, grant me permission to use Wi-Fi internet facility on the
university campus. For the same reason, I am enclosing necessary details as follows:
Personal Details
Name :-
Designation / Class :-
Employee Code / PRN NO: -
Department / School :-
User Type:- (Staff / Student):- Contact No:-
Academic Year (For student) from: 20 up to: 20 (Account will be deleted on 1st Jun of up to year)
Date of Retirement (for staff): (Account will be deleted on Date of Retirement)
Device Details:
(1) Company Name:- (2) Company Name:-
Model No:- Model No:-
Serial No:- Serial No:-
Mac Address:- Mac Address:-
Assigned IP Address:- Assigned IP Address:-
(Will be provided by computer network center) (Will be provided by computer network center)

Declaration
I hereby declare that, I will use the requested Wi-Fi internet facility only for research / educational
purposes. I will be liable, as per IT Act 2000 and its Amendments, for any misuse and/or neglect of this
Internet facility from my registered devices.

Date:- -------------- Signature of Applicant

-------------------------------------------------------For Office Use Only------------------------------------------------------

Recommendation of Head/Director:

(Head / Director of concern School /Department)

Director
School of Computer Sciences

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