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____________End of Instructions____________
GATE COPY
INDIAN General No
11. Address for Correspondence HANUMAN SARAN SRIVASTAVA 255/288 KA KUNDRI RAKABGANJ LUCKNOW 12. PINCODE of Address for 226004 Correspondence 13. Year of Degree 14. Discipline 15. Name of Parent 2005 Mathematics / Applied Mathematics HANUMAN SARAN SRIVASTAVA Uttar Pradesh
7. Qualifying Degree
M.Sc./M.C.A./M.A.
09415466333
I hereby declare that all the particulars stated in this application form are true to the best of my knowledge and belief. 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 opportunity to appear in GATE 2012. Further, if any such suppression or distortion of facts is found after appearing in the exam, any admission/degree acquired on the basis of GATE 2012 score is liable to be cancelled. Place : Date :
18. Signature
19. Photograph
Full Signature of the candidate using BLACK INK PEN only (do not sign in CAPITAL LETTERS)
3.5 cm x 3.5 cm
511MA5085656
Send this form along with the necessary documents to IIT Kanpur.
CANDIDATE COPY
INDIAN General No
11. Address for Correspondence HANUMAN SARAN SRIVASTAVA 255/288 KA KUNDRI RAKABGANJ LUCKNOW 12. PINCODE of Address for 226004 Correspondence 13. Year of Degree 14. Discipline 15. Name of Parent 2005 Mathematics / Applied Mathematics HANUMAN SARAN SRIVASTAVA Uttar Pradesh
7. Qualifying Degree
M.Sc./M.C.A./M.A.
09415466333
I hereby declare that all the particulars stated in this application form are true to the best of my knowledge and belief. 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 opportunity to appear in GATE 2012. Further, if any such suppression or distortion of facts is found after appearing in the exam, any admission/degree acquired on the basis of GATE 2012 score is liable to be cancelled. Place : Date :
18. Signature
19. Photograph
Full Signature of the candidate using BLACK INK PEN only (do not sign in CAPITAL LETTERS)
3.5 cm x 3.5 cm
511MA5085656
BY SPEED / REGISTERED POST (Please do not Courier) GATE 2012 Application Form
511MA5085656
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From
ANSHUL SRIVASTAVA (APPLNO : 5085656) HANUMAN SARAN SRIVASTAVA 255/288 KA KUNDRI RAKABGANJ LUCKNOW 226004
Date of Deposit : DD/MM/YY (to be treated by Applicant as fee receipt) Account to be Credited : 0036SLFEECOL
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1.Institution Name : 2.Student/Applicant Name : 3.Roll No/Application No : 4.Class/DOB : 5.Section/Category : 6.Amount : 7.Amount in words : 8.Cash Details : Denomination 1000 X 500 X 100 X
1.Institution Name : 2.Student/Applicant Name : 3.Roll No/Application ID : 4.Class/DOB : 5.Section/Category : 6.Amount : 7.Amount in words : 8.Cash Details : Denomination 1000 X 500 X 100 X
1.Institution Name : 2.Student/Applicant Name : 3.Roll No/Application ID : 4.Class/DOB : 5.Section/Category : 6.Amount : 7.Amount in words : 8.Cash Details : Denomination 1000 X 500 X 100 X
5085656
5085656
5085656
22/01/83 NA Rs.1025/- * Rupees One thousand and Twenty Five Only. (*Including Rs. 25 as Bank Charge)
22/01/83 NA Rs.1025/- * Rupees One thousand and Twenty Five Only. (*Including Rs. 25 as Bank Charge)
22/01/83 NA Rs.1025/- * Rupees One thousand and Twenty Five Only. (*Including Rs. 25 as Bank Charge)