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3. 4.
Put
7.
____________End of Instructions____________
GATE COPY
11. Address for Correspondence 48, SATHIYA SAI NAGAR 3RD CROSS, 2ND LANE RAJAKILLPAKAM CHENNAI 12. PINCODE of Address for 600073 Correspondence 13. Year of Degree 14. Discipline 15. Name of Parent 2012 Instrumentation / Electronics / Control TVENKATESH Tamil Nadu
7. Qualifying Degree
09791137327
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
703IN7090155
Send this form along with the necessary documents to IIT Madras.
CANDIDATE COPY
11. Address for Correspondence 48, SATHIYA SAI NAGAR 3RD CROSS, 2ND LANE RAJAKILLPAKAM CHENNAI 12. PINCODE of Address for 600073 Correspondence 13. Year of Degree 14. Discipline 15. Name of Parent 2012 Instrumentation / Electronics / Control TVENKATESH Tamil Nadu
7. Qualifying Degree
09791137327
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
703IN7090155
BY SPEED / REGISTERED POST (Please do not Courier) GATE 2012 Application Form
703IN7090155
Do not tamper with the bar code. For GATE official use.
From
V B U V A N E S H (APPLNO : 7090155) 48, SATHIYA SAI NAGAR 3RD CROSS, 2ND LANE RAJAKILLPAKAM CHENNAI 600073