4/2/13 IITM - M.Tech Application
mtechadm.iitm.ac.in/gform5.php?appno=115393431322380038 1/1
M.Tech. 2013 Admissions (Regular)GATE Office - IIT Madras -
Chennai 600 036
Application form for Admission to M.Tech. Programmes for the
year 2013 1. Application Number: 43132 2. Name: Anil Kumar
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3. GATE 2013 Reg.No: EE 32202006 (Score: 384)4. Category/PD: OBC
(Non-Creamy) / Yes5. Gender / Nationality: Male / Indian6. Date of
Birth: 20/10/937. Qualifying Degree: B.Tech.8. Qualifying
Discipline: Electrical & Electronics Engineering (EE)9.
Qualifying Status: Final Exam Appeared and Awaiting Results10.
Qual. Month / Year: May - 201311. Marks / CGPA: CGPA: 7.20/1012.
College / Inst. Name / University: Malaviya National Institute of
Technology Jaipur / DEEMED UNIVERSITY13. M.Tech. Course Codes: (As
per order of preference)
1st Choice 2nd Choice 3rd Choice 4th Choice 5th Choice 6th
Choice 7th Choice 8th Choice EE2Y EE4Y
14. Address: RAILWAY STATION KI DHANI CHIRAWA DISTT-JHUNJHUNU
RAJASTHAN PIN: 33302615. Email Id: [email protected](a). Phone
Number: 01596223853 16(b). Mobile: 759784966317. Demand Draft
Details: (in favour of "The Registrar, IIT Madras" payable at
Chennai; Write AppNo and Name on the reverse side of the DD)
DD Number DD Date Drawn on DD Amount (Rs.)
555675 28/03/13 STATE BANK OF INDIA ,CHIRAWA 100 Declaration by
the Applicant
I have not been admitted to any academic programme in the
country on the basis of GATE SCORE(s) for the year(s) given in this
application. I declare that no part of my
degree is through correspondence programme. If selected for
admission, I agree to abide by the rules and regulations of the
Institute. I certify that the information
furnished in this application is true to the best of my know
ledge and belief. I understand that furnishing false information w
ill lead to forfeiture of admission, if offered.
Place:Date: Signature of the CandidateNote: Send this form after
entering the particulars of DD and affixing the photograph and
signature, along with copy of SC/ST/OBC (Non-Creamy
Layer) certificate in proper format, if applicable, and DD for
Rs.200 (Rs.100 for SC/ST/PD) drawn in favour of "The Registrar, IIT
Madras" payable at
Chennai BY SPEED POST ONLY to 'The Chairman, M.Tech. Admission
Committee, GATE Office, IIT Madras, Chennai 600 036' to reach on or
before 05-
04-2013.
