GATE2012_5010021

8.

Page - 4 : Address page to be pasted on a 10 inch X 12 inch size laminated envelope.

7.

Instructions for the Candidate:

1.

2.

Page - 1: Instructions for the candidate to be retained by the candidate.3.

4.

5.

a. Paste your recent color photo (3.5cm x 3.5cm) in the designated place. Before pasting, please writeyour name and application number on the backside of the photo with black ball point pen.

6.

There are 5 pages in this pdf file. These pages should be printed on A4 size white sheets using alaser/ink jet printer.

Page - 2 : Application Form (GATE Copy).

Page - 3 : Application Form (Candidate copy) to be retained by the candidate.

Instructions and Application Form for GATE 2012

1. Application Form (GATE Copy)

2. Bank Challan (GATE Copy)

3. Self Attested Copy of SC/ST/PD certificate (if applicable)

4. Self Attested Copy of affidavit for change of name (if applicable)

Your Login ID is ATUL0804. Remember your password and do not disclose it to anyone.

Without folding, insert the completed Application Form (GATE copy) and attested copies of all theapplication documents (SC/ST/PD certificate, copy of degree certificate etc.) into a 10 inch X 12 inchlaminated envelope and send by Speed Post (preferably) or by Registered Post using the addressprinted on page-4 so as to reach the respective Zonal GATE office on or before 24th October 2011.

List of Documents to be attached with the Application Form:

5. Self Attested Copy of the degree certificate if the year of qualifyingdegree is 2011 or earlier.

6. If the year of qualifying degree is 2012 or later, a certificate signed bythe principal of the college clearly indicating the year of qualifyingdegree (format available on GATE website).

____________End of Instructions____________

Application sent through courier will not be accepted.

Put

Page - 5 : Bank challan in triplicate. Take it to any SBI branch and pay the application fee plus the bankservice charge. The Bank will retain its copy and will return the remaining two copies to you. Out ofthese two copies, retain the Candidate's copy with you and attach the GATE copy with the ApplicationForm.

b. Sign at the designated place.

Mechanical EngineeringATUL KUMAR PANDEYName of the Candidate as inthe 10th Class Certificate

Choice of GATE Paper1. 9.

GATE COPYAPPLICATION NO. 5010021

GATE 2012 APPLICATION FORM

Zone: IIT Kanpur Payment Mode: Bank Challan (SBI) Fee: Rs. 1000

Date of Birth (DD/MM/YYYY)2. E-mail Address [email protected]/04/1991 10.

Gender3. MALE Address for Correspondence RB-3,304/4 CRWS COLONY,11.rb-3,304/4 crws colony

Category

Person with Disability (PD)

Nationality

Year of Degree

Discipline

5.

6.

4.

13.

14.

General

No

INDIAN

2012

Mechanical Engineering

PINCODE of Address forCorrespondence

12. 462010

Qualifying Degree

Choice of Examination City1


Name of Parent

State/Union Territory ofPermanent Residence

7.

8.

15.

16.B.E./B.Tech./ B.Sc.(Engg.)/B.Sc.(Tech.)/B.Arch.

505 - Bhopal

511 - Lucknow

A L PANDEY

Madhya Pradesh

I hereby declare that all the particulars stated in this application form are true to the best of my knowledge andbelief. I have read the contents of GATE 2012 website and I shall abide by the terms and conditions therein. Inthe event of suppression or distortion of any fact in my application form, I understand that I will be denied theopportunity to appear in GATE 2012. Further, if any such suppression or distortion of facts is found afterappearing in the exam, any admission/degree acquired on the basis of GATE 2012 score is liable to becancelled.

Mobile / Landline No.17. 07552746085

Place :

Date :

Full Signature of the candidate usingBLACK INK PEN only

(do not sign in CAPITAL LETTERS)

505ME5010021

19. Photograph18. Signature

3.5 cm x 3.5 cm

Send this form along with the necessary documents to IIT Kanpur.

Mechanical EngineeringATUL KUMAR PANDEYName of the Candidate as inthe 10th Class Certificate

Choice of GATE Paper1. 9.

CANDIDATE COPYAPPLICATION NO. 5010021

GATE 2012 APPLICATION FORM

Zone: IIT Kanpur Payment Mode: Bank Challan (SBI) Fee: Rs. 1000

Date of Birth (DD/MM/YYYY)2. E-mail Address [email protected]/04/1991 10.

Gender3. MALE Address for Correspondence RB-3,304/4 CRWS COLONY,11.rb-3,304/4 crws colony

Category

Person with Disability (PD)

Nationality

Year of Degree

Discipline

5.

6.

4.

13.

14.

General

No

INDIAN

2012

Mechanical Engineering

PINCODE of Address forCorrespondence

12. 462010

Qualifying Degree



Name of Parent

State/Union Territory ofPermanent Residence

7.

8.

15.

16.B.E./B.Tech./ B.Sc.(Engg.)/B.Sc.(Tech.)/B.Arch.

505 - Bhopal

511 - Lucknow

A L PANDEY

Madhya Pradesh

I hereby declare that all the particulars stated in this application form are true to the best of my knowledge andbelief. I have read the contents of GATE 2012 website and I shall abide by the terms and conditions therein. Inthe event of suppression or distortion of any fact in my application form, I understand that I will be denied theopportunity to appear in GATE 2012. Further, if any such suppression or distortion of facts is found afterappearing in the exam, any admission/degree acquired on the basis of GATE 2012 score is liable to becancelled.

Mobile / Landline No.17. 07552746085

Place :

Date :

Full Signature of the candidate usingBLACK INK PEN only

(do not sign in CAPITAL LETTERS)

505ME5010021

19. Photograph18. Signature

3.5 cm x 3.5 cm

Retain this copy with you for future reference.

To

BY SPEED / REGISTERED POST(Please do not Courier)

Chairman, GATE

GATE 2012 Application Form

Indian Institute of Technology Kanpur

FromATUL KUMAR PANDEY (APPLNO : 5010021)

RB-3,304/4 CRWS COLONY,

Kanpur - 208016

Do not tamper with the bar code. For GATE official use.

rb-3,304/4 crws colony

462010

GeneralGeneralGeneral

[email protected]@[email protected]

075527460850755274608507552746085

RB-3,304/4 CRWS COLONY, rb-3,304/4 crws

colony - 462010


colony - 462010


colony - 462010

ATUL KUMAR PANDEYATUL KUMAR PANDEYATUL KUMAR PANDEY

1. Please note to write the Journal Number in all the challans.2. Please feed the Application No. in REG/ID/Ref No. Column.

SEAL / DATE AUTHORISED SIGNATORY

E Mail ID :

Category :

Address forCorrespondence :

08/04/1991

Mobile / Landline No:

CASH VOUCHER BANK COPY

GATE 2012 – Application Fee Payment Challan

Name of the Candidate :

Signature of the Candidate/Remitter

For Receiving Branch use only

Registration ID / Ref No. : 5010021

Category :

CASH VOUCHER

JOURNAL NUMBER



E Mail ID :




Category :

CASH VOUCHER



E Mail ID :




GATE COPY CANDIDATE COPY

CASH CAN BE TENDERED AT ANY SBI BRANCH

Use CBS Screen No. :

FEE Type :

Date of Birth :

16

8888

Amount :

Amount in words :

Rs.1025/- *

Rupees One thousand and Twenty Five Only.(*Application Fees Including Bank Charges)


Amount :

Amount in words :

Rs.1025/- *


JOURNAL NUMBER


08/04/1991



FEE Type :

Date of Birth :

16

8888





JOURNAL NUMBER

Rs.1025/- *


Amount :

Amount in words :


08/04/1991



FEE Type :

Date of Birth :

16

8888


Challan can be deposited minimum one day after thegeneration of challan.



Last date for acceptanceof challan in bank : 24 October 2011.

