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Last Date for Submission 31.03.2011
M.Tech
Bank Demand Draft No. Date Amount
154941 2011-03-21 Rs.500/-
INDIAN SCHOOL OF MINES DHANBAD - 826 004
APPLICATION FOR ADMISSION TO 4-SEMESTER M.TECHCOURSE
(2011-12)
Affix your recent
self-attested
passport size
photograph
Registration No
MT0641
Name in full (BLOCK LETTERS)
KOTAMRAJU NATARAJBHARGAV
Parent's Name
Father Mother
KOTAMRAJU SRINIVASA RAO KOTAMRAJU BALA PADMAJA
Address for Correspondence (IN BLOCK LETTERS)
D.NO 6-5-71. 5/2 ARUNDEL PET. GUNTUR-522002. ANDHRA PRADESH.
INDIA
District State
GUNTUR Andhra Pradesh
Pin Code Phone No.
522002 9394119566
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Permanent Address
D.NO. 6-5-71. 5/2 ARUNDEL PET. GUNTUR-522002. ANDHRA PRADESH.
INDIA.
District State
GUNTUR Andhra Pradesh
Pin Code Phone No.
522002 9394119566
Email
[email protected]
Date of Birth Age as on 1st July 2010
1990-07-07 20 yrs 11 mths 24 days
Sex Nationality
Male India
Category (GN/OB/SC/ST/PS/JK/DP/PC)
GN
GATE Qualified
Yes
Details of the GATE Exam.
Category
N/A
Marks out of 100 GATE Score Score card valid upto
32.67 394 2012-03-15
Gate Card Registration Subject of ExaminationQualifying Marks as
per
Claimed in GATE
EC 7092129ELECTRONICS AND
COMMUNICAION26.11
Discipline Preference on Priority Basis for Admission
1) Electronics and Communication Engineering
2) Computer Application
3) Industrial Engg. and Management
Mention the centre of written test (Only for GATE NOT
QUALIFIED/Sponsored
Candidates)
N/A
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Subject for Written Test
N/A
Academic Record
Name of theExamination
School /College
Board /University
Year ofpassing
% of marksobtained
Subjects
B.TECH
VASIREDDY
VENKATADRI
INSTITUTE OF
TECHNOLOGY
JNTU-K 2011 64.2 ECE
INTERMEDIATE
PUBLIC
EXAMINATION
BHASHYAM
JUNIOR
COLLEGE
BOARD OF
INTERMEDIATE
EDUCATION ,
A.P
2007 90.9 MPC(MATHEMATICS,PHYSICS,C
SSC
EXAMINAITON
KENNEDY
SCHOOL
BOARD OF
SECONDARYEDUCATION, A.P
2005 65.2 SCIENCE
Employment Record
Name of the
employers with
addresses
Position
heldPeriod From Period To
Basic Pay &
Total
Emoluments
Nature of
work
N/A N/A N/A N/A N/A N/A
N/A N/A N/A N/A N/A N/A
N/A N/A N/A N/A N/A N/A
N/A N/A N/A N/A N/A N/AN/A N/A N/A N/A N/A N/A
(a) Attach separate additional sheet (if required)
(b) Certificate from the sponsoring authority (for employed
candidate)
(Employed candidate must submit application through his/her
employer)
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Certified that the information furnished by the applicant under
item Sex, Academic Record and Employee
Record are correct and that his / her conduct is good.
We hereby Sponsor the candidate of Shri/
Smt./Kum________________________, an employee in our
organization, for joining his / her M.Tech Programme in
_____________ at your Institute as a fulltime
candidate.
He / She is employee of our organization for ________________
years. We shall bear the total expenses ofhis / her studies. We
Shall fully relieve him / her of his / her duties in the
organization during the entire period
of the M.Tech. programme, to enable him / her to devote full
time to his / her studies in this Institute.
Note: Candidates with CSIR/UGC/ Atomic Energy, fellowship shall
not be treated as a sponsored candidate.
Signature of the forwarding officer with stamp
Name
Designation:
Deptt/ Office:
Date:
Place:
Place
GUNTUR
Date
2011-03-22
Signature of Applicant
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