-- :: Application Form For Employment :: --

Registration No. : 69623

I. POSITION DETAILS
Name of Post Pay scale Grade : : : EXEC UTIVE TRAINEE (INSTRUMENTATION) Rs. 24900-50500 E2

II. PERSONAL DETAILS

1. GATE-2013 Registration Number (Enter GATE-2013 Registration No. which is mentioned on your GATE-2013 admit card )

IN62132740

2. Name (Name should be filled up as appearing in your GATE 2013 admit card)

First Name

ANIRUDDHA

Middle Name

Last Name

MAITY

3. Date of Birth

09/04/1990

4. Father's Name 5. Category 6. Name of Caste / Tribe (In case of SC/ST/OBC) 7. Other Category, If Applicable (i) (ii) (iii) Persons with disabilities Ex-Serviceman Domiciled in J&K between 01.01.1980 and 31.12.1989

: : :

ASWINI KUMAR MAITY GENERAL NA

: : :

NO NO NO

8. Details (In case of PWD) (i) (ii) Type of Disability Percentage (%) of Disability : : NA 0

9. Details (In case of Ex-Serviceman) (i) (ii) (iii) (iv) Rank C orps / Regiment Number Date of C ommission Date of Discharge : : : : NA NA NA NA 1/3

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(v) (vi) (vii)

Date of start of pre-commission training, if any Education of Military Length of service

: : : : : : :

NA NA 0 YEAR(S) 0 MONTH(S) 0 DAY(S) INDIAN HINDUISM MALE SINGLE

10. Nationality 11. Religion 12. Sex 13. Marital Status 14. Present Postal Address (i) (ii) (iii) (iv) (v) (vi) (vii) 1st Address Line 2nd Address Line 3nd Address Line C ity District State PIN C ode

: : : : : : : : : :

VILL-BURIKHALI P.O-BURIKHALI P.S-BAURIA BAURIA HOWRAH WEST BENGAL 711310 STD C ode: 33 8420608670 ANI.C HALLENGER90@GMAIL.C OM Number: 26428253

(viii) Telephone (Landline) (ix) Telephone (Mobile)

15. Present e-mail Address

III. Education & Experience Details

1. Essential Qualification Details :

Examination / Branch/Discipline/Specialization Degree Passed SSC (10th) HSC (10+2) BE / B TEC H / BSc(ENGG) SC IENC E ELEC TRONIC S & INSTRUMENTATION

C ollege / Institution BURIKHALI KM INSTITUTION BURIKHALI KM INSTITUTION HERITAGE INSTITUTE OF TEC HNOLOGY

Year of Joining 2003 2006

Year of Passing 2005 2007

Board / University WBBSE WBC HSE

Percentage of Marks * 81.37 76.8

Type FULL TIME FULL TIME

2008

2012

WBUT

70.9

FULL TIME

* Percentage of marks to be calculated taking average of all semesters/ years, irrespective of the weightages given to any particular semester/ year by the Institute/ University. Wherever, C GPA/ OGPA or letter Grade in a Degree is awarded, equivalent percentage of marks should be indicated in the application as per norms adopted by University/ Institute. C andidates currently in the final year (2012-13) of their Engineering Degree course should indicate percentage of marks received in aggregate up to the last semester examination at the time of applying.

2. Post Qualification Work Experience Details : I. Do You have any post qualification work experience : NO

II. C urrent / Last C ompany Name III. From Date (DD/MM/YYYY) IV. To Date (DD/MM/YYYY)

NA NA NA

IV. DECLARATION

12/28/12 I certify that a) I am not

-- :: Application Form For Employment :: --

employed in Govt. /Statutory Organization /Public Sector Undertaking.

b) In case of my employment in Government / Statutory Organization / Public Sector Undertaking, I will produce No Objection C ertificate (NOC ) from my organization at the time of Interview, if called for.

I declare that all information given in this application form are true to the best of my knowledge and belief. If any of the information is found incorrect or distorted at any stage, I shall have no objection to cancellation of my candidature.

ANIRUDDHA MAITY (Name & Signature) Date: 29/12/2012

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