GATE2012_6092884

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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

Your Login ID is AMRI010713. 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 inch

laminated envelope and send by Speed Post (preferably) or by Registered Post using the address

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.

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laminated envelope and send by Speed Post (preferably) or by Registered Post using the address

Electronics and CommunicationEngineering

AMRITYAM ROUTName of the Candidate as inthe 10th Class Certificate

Choice of GATE Paper1. 9.

GATE COPYAPPLICATION NO. 6092884

GATE 2012 APPLICATION FORM

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

Date of Birth (DD/MM/YYYY)2. E-mail Address [email protected]/07/1991 10.

Gender3. MALE Address for Correspondence C/O-GHANASHYAM ROUT,11.

AT-JOHNSUN BHAWAN,

SISU MANDIR ROAD, SALIPUR,

CUTTACK,ODISHA-754202

Category

Person with Disability (PD)

Nationality

Year of Degree

Discipline

5.

6.

4.

13.

14.

General

No

INDIAN

2012

Electronics & Comm./ElectronicsEngg./CommunicationEngg./Telecommunication Engg

PINCODE of Address forCorrespondence

12. 754202

Qualifying Degree

Choice of Examination City1


Name of Parent

State/Union Territory of

Permanent Residence

7.

8.

15.

16.B.E./B.Tech./ B.Sc.

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

604 - Bhubaneswar

606 - Cuttack

GHANASHYAM ROUT RAMASUNDARA

Orissa

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. In

the event of suppression or distortion of any fact in my application form I understand that I will be denied the

Mobile / Landline No.17. 09090725253

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Electronics and CommunicationEngineering

AMRITYAM ROUTName of the Candidate as inthe 10th Class Certificate

Choice of GATE Paper1. 9.

CANDIDATE COPYAPPLICATION NO. 6092884

GATE 2012 APPLICATION FORM

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

Date of Birth (DD/MM/YYYY)2. E-mail Address [email protected]/07/1991 10.

Gender3. MALE Address for Correspondence C/O-GHANASHYAM ROUT,11.

AT-JOHNSUN BHAWAN,



Category

Person with Disability (PD)

Nationality

Year of Degree

Discipline

5.

6.

4.

13.

14.

General

No

INDIAN

2012

Electronics & Comm./ElectronicsEngg./CommunicationEngg./Telecommunication Engg

PINCODE of Address forCorrespondence

12. 754202

Qualifying Degree



Name of Parent

State/Union Territory of

Permanent Residence

7.

8.

15.

16.B.E./B.Tech./ B.Sc.

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

604 - Bhubaneswar

606 - Cuttack

GHANASHYAM ROUT RAMASUNDARA

Orissa

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. In

the event of suppression or distortion of any fact in my application form I understand that I will be denied the

Mobile / Landline No.17. 09090725253

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To

BY SPEED / REGISTERED POST(Please do not Courier)

Chairman, GATE

GATE 2012 Application Form

Indian Institute of Technology Kharagpur

From

AMRITYAM ROUT (APPLNO : 6092884)

C/O-GHANASHYAM ROUT,

Kharagpur - 721302

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

604EC6092884

AT-JOHNSUN BHAWAN,



754202

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GeneralGeneralGeneral

[email protected]@[email protected]

090907252530909072525309090725253

C/O-GHANASHYAM ROUT, AT-JOHNSUN

BHAWAN, SISU MANDIR ROAD, SALIPUR,

CUTTACK,ODISHA-754202 - 754202







AMRITYAM ROUTAMRITYAM ROUTAMRITYAM ROUT

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 :

01/07/1991

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. : 6092884

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


01/07/1991



FEE Type :

Date of Birth :

16

8888





JOURNAL NUMBER

Rs.1025/- *


Amount :

Amount in words :


01/07/1991



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.



Documents

GATE2012_6092884