Mechanical EngineeringSAURABH KUMAR
Name of the Candidate as inthe 10th Class CertificateChoice of GATE Paper
GATE COPYAPPLICATION NO.8066914
GATE 2012 APPLICATION FORM
Payment Mode: Bank Challan (SBI)Fee:Rs. 1000
Date of Birth (DD/MM/YYYY)
Address for Correspondence
VILL+POST -MOHAN PUR11.KHAD MOHAN NAGARDIST- BULANDSHAHR
CategoryPerson with Disability (PD)NationalityYear of DegreeDiscipline
PINCODE of Address forCorrespondence
Qualifying DegreeChoice of Examination City1Choice of Examination City2Name of ParentState/Union Territory ofPermanent Residence
22.214.171.124.B.E./B.Tech./ B.Sc.(Engg.)/B.Sc.(Tech.)/B.Arch.806 - Ghaziabad818 - NoidaRAM KUMAR SHARMAUttar 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.
Place :Date :
Full Signature of the candidate usingBLACK INK PEN only(do not sign in CAPITAL LETTERS)
3.5 cm x 3.5 cm
Send this form along with the necessary documents to IIT Roorkee.