APPLICATION NO.

(To be alloted by Office)

INDIAN INSTITUTE OF TECHNOLOGY ROORKEE
APPLICATION FORM FOR
M.TECH./M.ARCH./M.U.R.P. ADMISSION-2011 A Passport Size
(Please read the instructions from the Information Brochure Photograph
should be
given on Institute Website before filling the Form)
pasted in this
space

1. Name of the Candidate(in Capital Letters) ..................................................................................

2. Father’s Name..............................................…… 3. Mother’s Name...............…………...

4. Date of Birth (DD/MM/YY) ............................. 5. Gender (Male/Female) ..........................

6. Nationality (Indian/Foreign) .............................

7. Category (GEN/SC/ST/OBC) ............................ 8. Person with Disability Yes / No

9. Qualifying Exam Passed Yes / No

10. Percentage of Marks/CGPA . if CGPA, Point Scale

11. Bachelor’s Degree from IIT Yes / No If yes, Name of the IIT ...................................

12. GATE Qualified Yes / No 13. GATE Discipline (Code)

14. GATE Marks Out of 100 . 15. GATE Qualifying Year 2 0

16. Whether Sponsored Candidate Yes / No , If Yes Admission required Full Time Part Time
(for candidates already in employement) (Please Tick )

17. Departments/Centres Applied (Please write Deptt. Codes maximum four as per Table-9 of Information Brochure-10)

1 st 2nd 3rd 4th

18. Codes of Academic Programme, Preference wise (As per Table-2 of Information Brochure-10)
Note: No change will be allowed later on.
1 st 2nd 3rd 4th 5th 6th 7th

8th 9th 10th 11th 12th 13th 14th

19. No. of Additional Departments Applied (0/1/2/3)

20. Amount of Application Fee including Fee for Additional Deptts. Paid (Rs.200-700) Rs.

21. Details of Demand Draft : No............................. Date.................. Bank’s Name ............................

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 22. Complete Postal Address for Correspondence (Write in CAPITAL Letters)
.................................................................................................................................................……

.................................................................................................................................................……

.................................................................................................................................................……

.............................................................................… Pin Code .........................….............……...

E-mail : …….................................………………… Mobile No. ..............................................…

Telephone No. (….............…) .............................. Fax No. (….............…)................................

STD CODE STD CODE

23. DECLARATION BY CANDIDATE

I hereby declare that all the particular stated by me in this Application Form are true to the best of my
knowledge and belief. I have read the Information Brochure of PG Admission-2011, IIT Roorkee given on
Institute Website and I shall abide by the terms and conditions given therein. It is entirely my responsibility,
to prove my eligibility for admission to the Programme(s) for which I am admitted and also, in respect of
qualifications and entitlement for admission against reserved category, if claimed, to the satisfaction of
the Institute. Further, in the event of suppression or distortion of any fact like category, educational
qualifications, nationality, etc., made in my Application Form, I understand that my admission, if granted
or degree/diploma acquired subsequently, is liable for cancellation. I also understand that the decision
of IIT Roorkee regarding my admission, will be final and I shall abide by the ordinances and regulations
of IIT Roorkee, in vogue form time to time. I have read Section 8.9 of the Information Brochure regarding
the institution’s approach toward ragging and the punishments to which I am liable if found guilty of
ragging. Further, if admitted, I promise to abide by the statutes, ordinances and regulations of IIT Roorkee.
I further declare that I have not taken admission and registered for any Postgraduate programme at the
Institute at the level for which I am applying.

24. Full Signature of candidate

Place...............................
Date………………………

Enclosures:
1. Copy of GATE score card
2. Copy of Final year marks sheet/Pre final year marks sheet
3. Candidates belonging to OBC category must submit Xeroxed copy of category certificate on
GOI format. Certificate should have been issued after 31.03.2010 by a competent authority.
4. Annexure 1 / 2 / 3 / 4 / 5 as applicable.

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 Annexure-1
CERTIFICATE FOR APPEARING IN THE FINAL SEMESTER/YEAR EXAMINATION
(Required from candidates who are yet to appear in the qualifying examination)
I hereby certify in connection with the application of Mr./Ms. ............................................... that he/she is a bonafide student of our institution
and is applying for admission to PG programme(s) at IITR. He/She is yet to complete the requirements of qualifying examination including
theory, practical and project examination for B.E./B.Tech./M.Sc./……............................ (Strike out the non-applicable ones and write in the
blank space if the degree is not mentioned) and the result is likely to be announced by ................................ 2011. The percentage of
aggregate marks/CGPA obtained by him/her upto prefinal year examination is ................................His/her conduct and character during his/
her stay at the Institute/University is “GOOD”.
Place: ................................................ Signature of the Principal/Dean/Registrar/
Date:.................................................. Dy. Registrar/Proctor/Administrative Officer/
Asstt.Registrar of the institute attending/last attended with seal

Annexure-2
SPONSORSHIP CERTIFICATE
(Required from full-time sponsored candidates only)
The undersigned is pleased to sponsor Mr./Ms. ............................................................ who is working in this organisation for the last
................... years and is presently holding the rank/position of ................................................. for pursuing the programme (course) at IIT
Roorkee in the Department of ............................. ............................................................................... with specialisation in the following
areas:
1. ........................................................ 2. ....................................................... 3. .................................................4. ................................................
His/her conduct and character has been good.
The Institution/Organization would relieve him/her immediately for joining the above course, if selected for admission. The Institution/
Organisation also agrees to pay the contingent/all expenses stipulated by the Institute. This is further certified that the sponsorship for
admission will not be withdrawn midway till completion of the course. Our enterprise is registered in a stock exchange/had an annual turn
over of over Rs. 5.0 crores in the past two years (for candidates working in a Firm/Company/Industry).
Place: ..................................... Signature of Head of the Institution/Organisation with seal
Date: ...................................... Name ..................................................................................
Designation ........................................................................

Annexure-3
NO OBJECTION CERTIFICATE
(Required from candidates seeking admission on part-time basis)
The undersigned is pleased to permit Mr./Ms. ............................................................ who is working in this organisation for the last ...................
years and is presently holding the rank/position of ................................................. for pursuing the programme (course) at IIT Roorkee in the
Department of ......................................... ............................................................................. with specialisation in the following areas:
1. ........................................................ 2. ....................................................... 3. .................................................4. ................................................
His/her conduct and character has been good.
The Institution/Organization would relieve him/her immediately for joining the above course, if selected for admission. If admitted the
candidate will be permitted to be present at the Institute as required by the academic schedule for a period of three years and will continue
to remain in service for the duration of the course.
Place: ..................................... Signature of Head of the Institution/Organisation with seal
Date: ...................................... Name ..................................................................................
Designation ........................................................................

Annexure-4
AUTHORITIES WHO MAY ISSUE CASTE/TRIBE CERTIFICATE
SC/ST/OBC candidates should submit certificate issued by any of the following authorities:
District Magistrate/Additional District Magistrate/Collector/Deputy Commissioner/Additional Deputy Commissioner/Deputy Collector/1st Class
Stipendiary Magistrate/City Magistrate/Sub-Divisional Magistrate/Taluka Magistrate/Executive Magistrate/Extra Assistant Commissioner/
Chief Presidency Magistrate/Additional Chief Presidency Magistrate/Presidency Magistrate/Revenue Officer not below the rank of Tehsildar/
Sub-Divisional Officer of the area where the candidate and/or his/her family normally resides/Administrator/Secretary to Administrator/
Development Officer (Lakshadweep Island).
(Certificate issued by any other authority will be rejected.)
Annexure-5
CERTIFICATE FOR NON-DECLARATION OF RESULT
(Required during registration from candidates whose result of the qualifying examination has not been declared)
I hereby certify that Mr./Ms. ............................................... has appeared in the final year examination including theory, practical and project
examination for B.E./B.Tech./M.Sc/……… degree (strike out the non-applicable ones and write in the blank space if the degree is not
mentioned) and the result is likely to be announced by ................................ 2011. The percentage of aggregate marks/CGPA obtained by him/
her in the pre-final year examination is ........................ . His/her conduct and character during his/her stay at the Institute/University/College
was “GOOD”.
Place: ................... Signature of the Principal/Dean/Registrar/
Date: .................... Dy. Registrar/Proctor/Administrative Officer/
Asstt. Registrar of the institute last attended with seal
(Registration without this certificate may not be allowed)