2

M.Tech. 2012

M.Tech. Admission Indian Institute of Technology Madras

FORM

M 05

Acceptance of Offer of Admission by the Candidate

Name of Candidate (Block Letters)

M.Tech. Application No.

Address :

PIN Code To The Chairman M.Tech Admission Committee GATE Office, IIT Madras Chennai 600036 Sir, With reference to your letter No.IITM/M.Tech. Admn. 2012, dated _______ 2012, I hereby accept your

offer of admission to M.Tech programme in the stream ______________________________________.

I enclose the following:

(i) Original GATE SCORE CARD based on which present offer has been made.

GATE Registration No.

(ii) A Demand Draft (Rs.10550/- for General/OBC (Non-Creamy Layer) candidates and Rs.5550/-for SC/ST candidates) towards Institute fee drawn in favour of “The Registrar, IIT Madras”, payable at Chennai, the details of which are given below:

Amount Rs.

Demand Draft No.

Date Name of the Bank Place of Issue

(iii) I am currently employed at (Organisation) ________________________________________ (location) _________________________________. I understand that I need to produce the relieving order from the competent authority of the employer at the time of admission on 25th July, 2012, failing which the offer of admission will be cancelled.

I am not employed.

I shall be reporting to the Institute at Student Activities Centre (SAC) on Wednesday, 25th July, 2012 at 8.30 a.m. for admission. Date: Place: Signature

M.Tech. 2012

M.Tech. Admission Indian Institute of Technology Madras

FORM

M 06

DECLARATION by the Candidate

Name of Candidate (Block Letters)

M.Tech. Application No.

Please tick [] any one of the options given below:

I do not wish to be considered for updating the M.Tech. stream allotted to me.

I wish to be considered for updating the M.Tech. stream, if vacancy arises.

Date : Signature

M.Tech. 2012

M.Tech. Admission Indian Institute of Technology Madras

FORM

M 07

DECLINING OFFER OF ADMISSION

Name of Candidate (Block Letters)

M.Tech. Application No.

Address :

PIN Code

Tick whichever is applicable below:

I am declining the present offer (No. IITM/M.Tech. Admn. 2012 dated ).

I am declining the present offer (No. IITM/M.Tech. Admn. 2012, dated ). However, I would like to be considered for the higher preferences (M.Tech. Programme) as given in my application.

Place :

Date : Signature

To The Chairman M.Tech Admission Committee GATE Office IIT Madras Chennai – 600 036

GENERAL INSTRUCTIONS AND ADMISSION SCHEDULE I. Reporting for Admission: You are required to report for admission at the Student Activities Centre (SAC) of this Institute and participate in the orientation programme as per the schedule given overleaf. II. You must bring the following documents at the time of reporting for admission: 1. Date of birth extract: A photocopy of your SSLC / SSC / Matriculation certificate along with the original. 2. Degree Certificate: Originals of degree/provisional degree and Grade Cards/Mark Sheets of all the semesters of your degree programme with one set of photo copies of the same. 3. Declaration by Parent: Declaration signed by your Parent/Guardian in the enclosed Form M 09. 4. Medical Fitness Certificate: Medical fitness certificate in the enclosed Form M 10. 5. Draft for Hostel Deposit and Charges (Hostellers only):

A Demand Draft for Rs.16,842/- towards hostel deposit and charges drawn in favour of ‘The Chairman, Council of Wardens, IIT Madras’ payable at Chennai.

6. Course Completion Certificate:

All the candidates admitted to M.Tech. programme at IIT Madras should have completed all the examinations including Viva-voce by July 15, 2012. If the results of the final examination are not yet announced, a Course Completion Certificate from the Head of your Institution must be produced in Form M 11. Such candidates must submit the Provisional Certificate on or before 30-09-2012.

7. Relief Certificate: Employed candidates must submit relief certificate from the employer at the time of admission, failing which the offer of admission will be cancelled. 8. Category Certificate: SC/ST/OBC (Non-Creamy Layer) candidates should produce the original and a photocopy

of the category certificate issued by the Competent Authority. 9. Hostel Accommodation: Accommodation list will be displayed in the website (http://ccwoffice.iitm.ac.in) and on the

Notice Board of the Chairman, Council of Wardens (Ph.No: 044 2257 8500) located next to SAC (Student Activities Centre) Building. On arrival, the students are requested to proceed to the hostel allotted.

Chairman M.Tech. Admission Committee

IIT Madras

(PTO)

M.Tech. 2012

M.Tech. Admission Committee Indian Institute of Technology Madras

FORM

M 08

M.Tech. Admission Schedule

Date & Day Time Programme Venue

25.07.2012 (Wednesday)

09:30 hrs. to

12:30 hrs.

Admission to M.Tech.

Student Activities Centre (SAC)

Orientation Programme

26.07.2012 (Thursday)

09:00 hrs. Welcome Function

Student Activities Centre (SAC)

09:45 hrs. Coffee Break

10:00 hrs. Introduction of:

Chairman, Council of Wardens Advisor-Sports / Cultural Training and Placement Officer Chief Medical Officer Chief Advisor, MITr, Advisor-Weaker Section & Foreign Students Academic Section Officers

10:30 hrs. Talk by Dean, Academic Courses, on Credit System, Relative Grading, Evaluation Pattern, Registration etc.

14:00 hrs. Visit to Department / Lab concerned / Registration of courses for First Semester/ Meeting with HoD / Faculty Advisor

Departments of IIT Madras

27.07.2012 (Friday)

10.00 hrs. English Diagnostic test CRC

30.07.2012 (Monday)

08:00 hrs. Commencement of classes for the First Semester

Rooms as indicated in the Slot-wise list*

*To visit intranet http://academic.iitm.ac.in

Note: Students who wish to come one day earlier may do so and report to the Chairman,

Council of Wardens IIT Madras between 9.00 a.m. and 5.00 p.m. on 24-07-2012.

M.Tech. 2012

M.Tech. Admission Indian Institute of Technology Madras

FORM

M 09

DECLARATION BY PARENT / GUARDIAN

[to be submitted at the time of Admission]

Name of Candidate (Block Letters)

M.Tech. Application No.

To The Chairman M.Tech. Admission Committee GATE Office IIT Madras

Sir,

In the event of the applicant, my son / daughter / ward, being admitted to the M.Tech.

programme at Indian Institute of Technology Madras, I undertake to pay regularly the amounts

due from him/her to the Institute towards tuition fee, mess charges, hostel seat rent, etc.,

within the prescribed dates.

Place: Date :

Signature of Parent/Guardian* : ……………………………………………..…………..

Name in Block Letters : ……………………………………………………..….. Profession : ………...………..……………………………………… Address : ..…………………………………………………………

………………………………………………………..…

….……………………………………….……………...

………………………………………………….……....

Pin Code

Phone No. with STD Code

Office Residence Mobile

E-mail, if available

Note: *In the case of guardian, please give the relationship in brackets below the signature.

M 10

CONFIDENTIAL

Medical History and Personal Particulars of Students joining at IIT Madras

1. Full Name (in Block Letters) …………………………………………………………………………………….…

2. Roll No. ……………………………………………………………………………………………….……………………….…

3. Name of Parent/Guardian ……………………………………………………………………………………………

4. Personal : Veg. / Non-Veg.

Abuse of substances (if any) : Smoking / Alcohol / Drugs / Any other

5. Past Medical/Surgical Treatment :

No Yes

5.1 Allergies/Bronchial Asthma/Tuberculosis

5.2 Abdomen including Urinary Tract

5.3 Locomotor system (Spinal/Vertebral column/Joints)

5.4 Cardiovascular system

5.5 Neurological disorders/Psychological disorders

5.6 Sexually-transmitted/Venereal Diseases/Skin

5.7 Hepatitis

5.8 Diabetes

5.9 Rheumatism

5.10 Thyroid disease

6. Family history of any major illness :

No Yes

6.1 Tuberculosis

6.2 Leprosy

6.3 Diabetes

6.4 Hypertension

6.5 Ischemic heart diseases

6.6 Psychiatric illness

6.7 Cancer

7. Identification marks : 1)

2)

8. Blood Group :

I declare that all the statements above are true and correct to the best of my knowledge. I fully understand that I am responsible for the accuracy of all statements given. Candidate’s Signature : ……………………………………………………………………………………………….. Counter signed by Parent/Guardian : …………………………………………………………………………. Date :

Place :

: 2 :

HEALTH CERTFICATE

1. Examination by a General Physician (M.D. in General Medicine) I, Dr. ……………………………………………………………………………………………….. after examining

(with necessary investigations) Mr./Ms. ………………………………………………………….………………

Son / Daughter of Mr./Ms. ………………………………………………………………………..…….……….

born on …………………………

CERTIFY:

Weight ……. Kg. Height ……. cm. Blood Pressure ……….. /…………. mm Hg.

Girth of Chest : (a) At rest ……………………. : (b) After deep inspiration ………………………..

Cardiovascular System : Heart …………………Heart Sounds …………………

Respiratory System :

Neurological System :

Psychological disturbance : Yes / No If yes, specify …………………………

Past Medical or Surgical Record :

Identified allergies :

Current treatments :

Current vaccination Status (All candidates who do not have adequate active/passive immunity against

diseases mentioned below should take these injections/adult booster dose as recommended, just before

joining the Institute and the date to be mentioned below):

VACCINATION AGAINST

DISEASES 1st Injection Last Booster

Date Yes / No Date Yes / No

BCG

Diphtheria – Tetanus - Poliomyelitis

Measles, Mumps, Rubella

Hepatitis B

Hepatitis A

Meningitis

Typhoid

Chicken Pox

Candidate’s Signature : …………………………………………………………….

: 3 :

2. Examination by Ophthalmologist*

Acuity of Vision

Far Vision Near Vision Colour Vision

Naked Eye With Glasses Naked Eye With Glasses

R.E.

L.E.

*Latest Optometrist’s Recommendations, if any to be attached in original. Remarks / Special Recommendation, if any :

I, Dr. …….………………………………………………………………..…………………….. have examined

(with necessary investigations) Mr./Ms. …………………………….………………………………… Son /

Daughter of Mr./Ms. ……..………………………………………….………….………………………. born

on ……………………………… and the above information given to the best of my knowledge are

correct and true.

Date : Place : Signature & Seal

3. Examination by ENT Specialist*

Inspection / hearing *Audiometry

Right Ear

Left Ear

*Latest Audiometry report to be attached in original. Remarks / Special Recommendations, if any. I, Dr. …….……………………………………………………………………………….. have examined (with

necessary investigations) Mr./Ms. ……………………………………………………...…… Son / Daughter

of Mr./Ms. ……..…………………………………………………………. born on ……………………… and

the above information given to the best of my knowledge are correct and true.

Date : Place : Signature & Seal

Candidate’s Signature : ………………………………………………………………………

: 4 :

INVESTIGATIONS

1. *Electrocardiogram Date ………………………….. Result …………………………

2. *Chest X-ray Date ………………………….. Result …………………………

3. *Sonography (whole abdomen) Date ………………………….. Result …………………………

4. *Urine Date ………………………….. Result …………………………

5. *Blood Tests Date ………………………….. Result …………………………

a) Blood Sugar (F/PP) Date ………………………….. Result …………………………

b) Urea/Creatinine Date ………………………….. Result …………………………

c) Peripheral Smear Study/HB% Date ………………………….. Result …………………………

d) Lipid Profile Date ………………………….. Result …………………………

e) Blood Group/typing (if not known) Date ………………………….. Result …………………………

f) HBS Ag Date ………………………….. Result …………………………

g) HIV – I & II Date ………………………….. Result …………………………

*All original investigation reports (only) to be attached.

Remarks / Special Recommendation, if any: Conclusion : Fit / Unfit to pursue higher education with a very tight academic schedule. Reason : Date : Place : Signature & Seal Candidate’s Signature : …………………………………………………………………………….

M.Tech. 2012

M.Tech. Admission Indian Institute of Technology Madras

FORM

M 11

COURSE COMPLETION CERTIFICATE

Certified that Mr./Ms. ………………………………………………, Roll No. ………….… final

year student of this College, has completed all the requirements including practical,

project, Viva-voce, etc. for the award of the degree, and

a) He/She has appeared for the final examination held during ……….………. 2012, the results of which are awaited.

b) He/She has passed the final examination

(Strike out either (a) or (b) whichever is not applicable)

Place : Signature & Name of Principal with Office Seal Date : Name of the College : University : NB: Selected candidate must have appeared for all the examinations including project viva for the

award of the qualifying degree by 15th July, 2012, otherwise the candidate is not eligible for admission even if the offer of admission to M.Tech. is issued by IIT Madras.