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3. 4.
8.
____________End of Instructions____________
GATE COPY
11. Address for Correspondence ROOM NO. F-09, GOVIND BHAWAN IIT ROORKEE ROORKEE UTTARAKHAND 247667 2013 Geology/ Geophysics BHAGWAN DAS NIRANKARI Rajasthan
12. PINCODE of Address for Correspondence 13. Year of Degree 14. Discipline 15. Name of Parent
7. Qualifying Degree
09897266447
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
826GG8003895
Send this form along with the necessary documents to IIT Roorkee.
CANDIDATE COPY
11. Address for Correspondence ROOM NO. F-09, GOVIND BHAWAN IIT ROORKEE ROORKEE UTTARAKHAND 247667 2013 Geology/ Geophysics BHAGWAN DAS NIRANKARI Rajasthan
12. PINCODE of Address for Correspondence 13. Year of Degree 14. Discipline 15. Name of Parent
7. Qualifying Degree
09897266447
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
826GG8003895
BY SPEED / REGISTERED POST (Please do not Courier) GATE 2012 Application Form
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From
AVINASH NIRANKARI (APPLNO : 8003895) ROOM NO. F-09, GOVIND BHAWAN IIT ROORKEE ROORKEE UTTARAKHAND 247667
CASH VOUCHER
CANDIDATE COPY
Challan can be deposited minimum one day after the generation of challan.
Name of the Candidate : AVINASH NIRANKARI Address for Correspondence :
Challan can be deposited minimum one day after the generation of challan.
Name of the Candidate : AVINASH NIRANKARI
Challan can be deposited minimum one day after the generation of challan.
Name of the Candidate : AVINASH NIRANKARI
ROOM NO. F-09, GOVIND BHAWAN IIT Address for Correspondence : ROORKEE ROORKEE UTTARAKHAND 247667
ROOM NO. F-09, GOVIND BHAWAN IIT Address for Correspondence : ROORKEE ROORKEE UTTARAKHAND 247667
ROOM NO. F-09, GOVIND BHAWAN IIT ROORKEE ROORKEE UTTARAKHAND 247667
09897266447 deatheater03@gmail.com
09897266447 deatheater03@gmail.com
09897266447 deatheater03@gmail.com
Scheduled Caste Rs.525/- * Rupees Five Hundred and Twenty Five Only. (*Application Fees Including Bank Charges)
Scheduled Caste Rs.525/- * Rupees Five Hundred and Twenty Five Only. (*Application Fees Including Bank Charges)
Scheduled Caste Rs.525/- * Rupees Five Hundred and Twenty Five Only. (*Application Fees Including Bank Charges)
JOURNAL NUMBER
JOURNAL NUMBER
JOURNAL NUMBER
Signature of the Candidate/Remitter For Receiving Branch use only 1. Please note to write the Journal Number in all the challans. 2. Please feed the Application No. in REG/ID/Ref No. Column.
Signature of the Candidate/Remitter For Receiving Branch use only 1. Please note to write the Journal Number in all the challans. 2. Please feed the Application No. in REG/ID/Ref No. Column.
Signature of the Candidate/Remitter For Receiving Branch use only 1. Please note to write the Journal Number in all the challans. 2. Please feed the Application No. in REG/ID/Ref No. Column.
SEAL / DATE
AUTHORISED SIGNATORY
SEAL / DATE
AUTHORISED SIGNATORY
SEAL / DATE
AUTHORISED SIGNATORY