Serial No.

INDIAN INSTITUTES OF TECHNOLOGY

BOMBAY, DELHI, GUWAHATI, HYDERABAD, KANPUR, KHARAGPUR, MADRAS, ROORKEE

APPLICATION FORM FOR ADMISSION UNDER JAM 2011

To be filled by candidates qualified in JAM 2011 and desirous of Admission to Academic Programmes of IITs covered
under JAM 2011. This Application should be sent only to “Organizing Chairman, JAM 2011, IIT Roorkee, Roorkee
247 667” and should reach on or before June 15, 2011.

Candidates qualified in JAM 2011 are eligible to apply for admission to the Master’s programmes provided they satisfy the
minimum educational qualification(s) (MEQ) and eligibility requirement(s) (ER) as outlined in the JAM 2011 brochure. Kindly
indicate the order of preferences for the Masters’ programmes you wish to apply in the Choice Sheet in item No 9. Fill all items
of this application form and affix your signature in all pages of this form. Send this form along with relevant enclosures as per
item No. 11 and a Demand Draft of Rs. 300/- (Rupees three hundred only) drawn from any branch of State Bank of India or
Punjab National Bank only in favour of “Chairman, JAM, IIT Roorkee” payable at Roorkee to the following address by
Speed Post.

The Organizing Chairman, JAM 2011, IIT Roorkee, Roorkee - 247 667

1. Name of the Applicant :

(in Capital Letters)

2 Registration Number in JAM 2011 :

3 Code of qualified Test Paper(s) :

4 All India Rank :

5(a) Category
(Strike out whichever not applicable) GEN OBC (Non-Creamy Layer) SC ST

5(b) Person with Physical Disability (PD)

(Strike out whichever not applicable) YES NO

6. Address for correspondence:

Photo of the
candidate
30 x 40 mm

Tel. No. with STD Code:

0

Mobile No.: 0

E-mail: ____________________________________________________________________

Signature of the Candidate

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7. Qualifying Examination Result (In the box to the right, write P for PASSED and A for AWAITED)

8. Details of the academic record (attach photo copies of certificate(s) and mark sheet(s)):

Examination Name of Board / Year of Aggregate*

Subjects / Papers Taken
Passed University Passing Marks (%)

10th Standard

12th Standard
(+2 or
equivalent)

Bachelor’s Provide details in Table I

Degree** (Ref. Page 3)

* Aggregate of all subjects, including languages and subsidiaries, for all years/ semesters of the programme

** If result is awaited, fill details up to pre-final year / semester.

Signature of the Candidate

2
 TABLE I
Marks obtained in all papers, including languages and subsidiaries, in
Bachelor’s Degree for all years / semesters of the programme*.

Marks / Grade Maximum Marks

S. No. Title of Paper
Obtained + for the Paper

I Year / 1st and 2nd semester

II Year / 3rd and 4th semester
III Year / 5th and 6th semester

Total I = Total II =
Aggregate % of Marks = (Total I / Total II) x 100 = %
* If result is awaited, fill details up to pre-final year/ semester
+
For candidates with letter grade, the photocopy of mark sheet with grading scheme followed by the
University / Institute must be enclosed Signature of the Candidate

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9. Choice Sheet: Academic programmes for JAM 2011
Registration Number in JAM 2011 :
Name of the Candidate :
Choose the programmes of interest that you are eligible for, based on the paper qualified in JAM 2011. If you have qualified in
more than one paper, you are eligible for programmes covered by both papers. Mention the order of preference (1, 2, 3, etc.) in
the last column. In the 'Order of Preference' column, mark 'X' against the programmes that you are NOT interested in. Please
note that the order of preference plays an important role in the admission process.
Note: If you have qualified in two papers in JAM 2011, and would like to choose programmes eligible under both the papers,
the order of preference should be combined. For example, a candidate qualifying both BT and CY can have an order of
preference such as 1 under BT, 2 under CY, 3 under BT, and so on.

Programmes Eligible for JAM 2011 Paper: BT

Order of
Code JAM Paper Programme Title Institute
Preference
104 BT M.Sc. Biotechnology (4 Semesters) IIT Bombay

110 BT M.Sc.-Ph.D. Dual Degree in Biotechnology IIT Bombay

112 BT M.Sc.-Ph.D. Dual Degree in Environmental Science & Engineering IIT Bombay

703 BT M.Sc. Biotechnology (4 Semesters) IIT Roorkee

Programme Eligible for JAM 2011 Paper: CA

Order of
Code JAM Paper Programme Title Institute
Preference
709 CA Master of Computer Applications (6 Semesters) IIT Roorkee

Programmes Eligible for JAM 2011 Paper: CY

Order of
Code JAM Paper Programme Title Institute
Preference
105 CY M.Sc. Chemistry (4 Semesters) IIT Bombay

111 CY M.Sc.-Ph.D. Dual Degree Programme in Energy IIT Bombay

112 CY M.Sc.-Ph.D. Dual Degree in Environmental Science & Engineering IIT Bombay

201 CY M.Sc. Chemistry (4 Semesters) IIT Delhi

301 CY M.Sc. Chemistry (4 Semesters) IIT Guwahati

401 CY M.Sc. Chemistry (4 Semesters) IIT Kanpur

501 CY Joint M.Sc.-Ph.D. Programme in Chemistry IIT Kharagpur

601 CY M.Sc. Chemistry (4 Semesters) IIT Madras

704 CY M.Sc. Chemistry (4 Semesters) IIT Roorkee

801 CY M.Sc. Chemistry (4 Semesters) IIT Hyderabad

Signature of the Candidate

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Registration Number in JAM 2011:

Programmes Eligible for JAM 2011 Paper: GG

Order of
Code JAM Paper Programme Title Institute
Preference
101 GG M.Sc. Applied Geology (4 Semesters) IIT Bombay

108 GG M.Sc.-Ph.D. Dual Degree in Applied Geology IIT Bombay

502 GG Joint M.Sc.-Ph.D. Programme in Geology IIT Kharagpur

701 GG M.Sc. Applied Geology (4 Semesters) IIT Roorkee

707 GG M.Tech. Geological Technology (6 Semesters) IIT Roorkee

Programmes Eligible for JAM 2011 Paper: GP

Order of
Code JAM Paper Programme Title Institute
Preference
102 GP M.Sc. Applied Geophysics (4 Semesters) IIT Bombay

109 GP M.Sc.-Ph.D. Dual Degree in Applied Geophysics IIT Bombay

708 GP M.Tech. Geophysical Technology (6 Semesters) IIT Roorkee

Programmes Eligible for JAM 2011 Paper: MA

Order of
Code JAM Paper Programme Title Institute
Preference
106 MA M.Sc. Mathematics (4 Semesters) IIT Bombay

111 MA M.Sc.-Ph.D. Dual Degree in Energy IIT Bombay

112 MA M.Sc.-Ph.D. Dual Degree in Environmental Science & Engineering IIT Bombay

113 MA M.Sc.-Ph.D. Dual Degree in Operations Research IIT Bombay

202 MA M.Sc. Mathematics (4 Semesters) IIT Delhi

302 MA M.Sc. Mathematics & Computing (4 Semesters) IIT Guwahati

402 MA M.Sc. Mathematics (4 Semesters) IIT Kanpur

504 MA Joint M.Sc.-Ph.D. Programme in Mathematics IIT Kharagpur

602 MA M.Sc. Mathematics (4 Semesters) IIT Madras

702 MA M.Sc. Applied Mathematics (4 Semesters) IIT Roorkee

705 MA M.Sc. Industrial Mathematics and Informatics (4 Semesters) IIT Roorkee

Signature of the Candidate

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Registration Number in JAM 2011:

Programmes Eligible for JAM 2011 Paper: MS

Order of
Code JAM Paper Programme Title Institute
Preference
103 MS M.Sc. Applied Statistics and Informatics (4 Semesters) IIT Bombay

113 MS M.Sc.-Ph.D. Dual Degree in Operations Research IIT Bombay

404 MS M.Sc. Statistics (4 Semesters) IIT Kanpur

Programmes Eligible for JAM 2011 Paper: PH

Order of
Code JAM Paper Programme Title Institute
Preference

107 PH M.Sc. Physics (4 Semesters) IIT Bombay

111 PH M.Sc.-Ph.D. Dual Degree in Energy IIT Bombay

112 PH M.Sc.-Ph.D. Dual Degree in Environmental Science & Engineering IIT Bombay

114 PH M.Sc.-Ph.D. Dual Degree in Physics IIT Bombay

203 PH M.Sc. Physics (4 Semesters) IIT Delhi

303 PH M.Sc. Physics (4 Semesters) IIT Guwahati

403 PH M.Sc. Physics (4 Semesters) IIT Kanpur

405 PH M.Sc.-Ph.D. Dual Degree in Physics IIT Kanpur

505 PH Joint M.Sc.-Ph.D. Programme in Physics IIT Kharagpur

603 PH M.Sc. Physics (4 Semesters) IIT Madras

706 PH M.Sc. Physics (4 Semesters) IIT Roorkee

802 PH M.Sc. Physics (4 Semesters) IIT Hyderabad

Declaration

I hereby declare that the order of preference given by me for my eligible programmes is final.

Signature of the Candidate

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10. Details of Demand Draft of Rs. 300/- (Rupees Three Hundred Only) drawn in favour of “Chairman, JAM, IIT Roorkee”
payable at Roorkee.

Amount Date of issue Number Name of the issuing Bank Branch

Rs. 300/- State Bank of India / Punjab National Bank

11. Documents to be enclosed: (Attach a photocopy of each document and tick √ the relevant box(s))

10th standard Certificate.

12th standard (10+2) Certificate showing the subjects passed.

Mark sheets (including title of papers taken) for all semesters/ all the years or up to pre-final
year/semester of the qualifying degree if the result is awaited.

Category Certificate of SC/ST (if applicable), issued by a competent authority (list given in
Appendix – II of the JAM 2011 Information Brochure).

Category Certificate of OBC (non-creamy layer) (if applicable), issued by a competent authority in the
format attached (No other format is acceptable).

Certificate to support the Person with Physical Disability (PD) status, if applicable, issued by a
Government Medical Board.

Please attach only photocopies. DO NOT SEND ORIGINALS.

Declaration:
I hereby declare that the particulars stated by me in this Application Form for Admission are true to the best of my
knowledge and belief. Moreover, I have verified the information given above and it is found to be correct. I have read the
Information Brochure of JAM 2011 and agree to abide by the terms and conditions therein. It is entirely my responsibility to
prove my eligibility for admission to the programme for which I may be admitted and also, in respects of qualification and
entitlement for admission against reserved category, if claimed, to the satisfaction of the Admitting Institute. Further, in the
event of suppression or distortion of any facts such as category, educational qualifications, nationality etc. made in my original
Application Form of JAM 2011 as well as in this Application Form for Admission, I understand that my admission, if granted,
and/or degree/ diploma acquired subsequently are liable to be cancelled/ withdrawn. I also understand that the decision of the
Organizing Institute and the Admitting Institute regarding my admission will be final and I shall abide by the ordinances and
regulations of the Admitting Institute in vogue from time to time. I further understand that the Order of Preferences for
programme(s) and corresponding Institute(s) given by me in this form are final and no alteration will be permissible
under any circumstances.

Place:

Date:
Signature of the Candidate
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 INDIAN INSTITUTES OF TECHNOLOGY
(Bombay, Delhi, Guwahati, Hyderabad, Kanpur, Kharagpur, Madras, Roorkee)

UNDERTAKING
To be given by a candidate whose qualifying examination result is awaited and hence is provisionally admitted.

1. Name :

2. Registration Number in JAM 2011 :

3. Test Paper(s) :

4. All India Rank(s) :

I understand that my admission to any of the IITs is provisional since I have not submitted the attested
copies of the qualifying examination certificate and/or mark sheet as per the eligibility criteria stated in
Sections 4 and 5 of the Information Brochure for JAM 2011.

I also understand that in the event of my failing to fulfill the eligibility criteria on or before
September 30, 2011, my provisional admission to any of the IITs will stand cancelled.

_____________________
Signature of the candidate

Place : _____________________

____________________________
Countersigned by Parent/ Guardian
Date : ______________________

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 JAM 2011
Organizing Institute: IIT Roorkee
(Bombay, Delhi, Guwahati, Hyderabad, Kanpur, Kharagpur, Madras, Roorkee)

COURSE COMPLETION CERTIFICATE

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

final year B.Sc. / B.Sc.Ed. / B.E student of this College,

a) He / she has appeared for the final examination held during ……….………. 2011, 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: Those who are appearing for qualifying examination after 15th July 2011 are not eligible for admission even if
offer of provisional admission is issued.

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 Proforma for Other Backward Class (OBC) Certificate
(CERTIFICATE TO BE PRODUCED BY OTHER BACKWARD CLASSES APPLYING FOR ADMISSIONS TO
CENTRAL EDUCATIONAL INSTITUTIONS (CEIs), UNDER THE GOVERNMENT OF INDIA)

This is to certify that Shri/Smt./Kum. _____________________________ Son/Daughter of Shri/Smt.

__________________________________ of Village/Town ________________________________ District/Division
__________________________ in the _________________________ State belongs to the ________________________
Community which is recognized as a backward class under:

(i) Resolution No. 12011/68/93-BCC(C) dated 10/09/93 published in the Gazette of India Extraordinary Part I Section I
No. 186 dated 13/09/93.
(ii) Resolution No. 12011/9/94-BCC dated 19/10/94 published in the Gazette of India Extraordinary Part I Section I No.
163 dated 20/10/94.
(iii) Resolution No. 12011/7/95-BCC dated 24/05/95 published in the Gazette of India Extraordinary Part I Section I No.
88 dated 25/05/95.
(iv) Resolution No. 12011/96/94-BCC dated 9/03/96.
(v) Resolution No. 12011/44/96-BCC dated 6/12/96 published in the Gazette of India Extraordinary Part I Section I No.
210 dated 11/12/96.
(vi) Resolution No. 12011/13/97-BCC dated 03/12/97.
(vii) Resolution No. 12011/99/94-BCC dated 11/12/97.
(viii) Resolution No. 12011/68/98-BCC dated 27/10/99.
(ix) Resolution No. 12011/88/98-BCC dated 6/12/99 published in the Gazette of India Extraordinary Part I Section I No.
270 dated 06/12/99.
(x) Resolution No. 12011/36/99-BCC dated 04/04/2000 published in the Gazette of India Extraordinary Part I Section I
No. 71 dated 04/04/2000.
(xi) Resolution No. 12011/44/99-BCC dated 21/09/2000 published in the Gazette of India Extraordinary Part I Section I
No. 210 dated 21/09/2000.
(xii) Resolution No. 12015/9/2000-BCC dated 06/09/2001.
(xiii) Resolution No. 12011/1/2001-BCC dated 19/06/2003.
(xiv) Resolution No. 12011/4/2002-BCC dated 13/01/2004.
(xv) Resolution No. 12011/9/2004-BCC dated 16/01/2006 published in the Gazette of India Extraordinary Part I Section I
No. 210 dated 16/01/2006.

Shri/Smt./Kum. ________________________ and/or his family ordinarily reside(s) in the __________________________

District/Division of ________________________ State. This is also to certify that he/she does not belong to the
persons/sections (Creamy Layer) mentioned in Column 3 of the Schedule to the Government of India, Department of
Personnel & Training O.M. No. 36012/22/93-Estt.(SCT) dated 08/09/93, modified vide OM No. 36033/3/2004 Estt.(Res.)
dated 09/03/2004, or the latest notification of the Government of India.

This certificate is being issued based on the annual income / status of the parents / guardian of the applicant
as on financial year ending March 31, 2010.

Dated:

District Magistrate/
Seal Deputy Commissioner, etc.

NOTE:
(a) The term ‘Ordinarily’ used here will have the same meaning as in Section 20 of the Representation of the People
Act, 1950.
(b) The authorities competent to issue Caste Certificates are indicated below:
(i) District Magistrate / Additional Magistrate / Collector / Deputy Commissioner / Additional Deputy
Commissioner / Deputy Collector / Ist Class Stipendiary Magistrate / Sub-Divisional Magistrate / Taluka
Magistrate / Executive Magistrate / Extra Assistant Commissioner (not below the rank of 1st Class
Stipendiary Magistrate).
(ii) Chief Presidency Magistrate / Additional Chief Presidency Magistrate / Presidency Magistrate.
(iii) Revenue Officer not below the rank of Tehsildar and
(iv) Sub-Divisional Officer of the area where the candidate and / or his/her family resides.

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