SUBMITTED ON : gate.iitd.ac.

in

ORGANISING INSTITUTE: INDIAN INSTITUTE OF TECHNOLOGY ROORKEE

ONLINE APPLICATION FORM FOR GATE 2009

COMPLETE MAILING ADDRESS INCLUDING NAME PHOTOGRAPH PASTE (DO NOT STAPLE) A RECENT FRONT FACIAL HIGH CONTRAST PHOTOGRAPH OF SIZE 3 CM X 4 CM. Photograph must not be larger than this

NAME:

SANJEEV KUMAR 31/61/01, Varun Path, Mansarover, Jaipur (Rajasthan)

ADDRESS:

PIN CODE:

302020

box or else the application is liable to be rejected. Do not get the photograph attested

Email Address: kumarsanjeev.net@gmail.com

361816

FULL SIGNATURE WITH BLACK BALLPOINT PEN

INFORMATION TO THE CANDIDATE: On the printed form, paste your PHOTOGRAPH and SIGN at the two specified places. Keep a photcopy of the form and the demand draft. Send the compeleted form along with the Demand Draft, a copy of the SC/ST/OBC (Non Creamy Layer)/PD certificate, (if applicable) to the CHAIRMAN, GATE, of the corrsponding zone (website of which has been used) by Speed/Registered Post.

APPLICATION NUMBER
NAME OF THE CANDIDATE EXAMINATION CITY CODE (1st Choice) EXAMINATION CITY CODE (2nd Choice)

: 361816 : SANJEEV KUMAR : Jaipur (308) : New Delhi (313)

DEMAND DRAFT DETAILS

BANK NAME BANK ID(MICRO NO) : STATE BANK OF INDIA : 000002000

DEMAND DRAFT NUMBER : 733973 AMOUNT : Rs. 900.00 Only

DATE OF ONLINE SUBMISSION (dd/mm/yy) : 16/10/08

DATE OF ISSUE (dd/mm/yy) : 16/10/08

OTHER DETAILS

:
: JAGDISH PURVEY : 09/10/80 : Male : Indian : NO :G : Rajasthan (RJ) GATE PAPER CODE QUALIFYING DEGREE QUALIFYING YEAR DISCIPLINE CODE COLLEGE CODE PIN CODE OF COLLEGE MOBILE/LANDLINE PHONE : : : : : : : EC E 2005 18 HR027 123506 09352841589

NAME OF PARENT DATE OF BIRTH (dd/mm/yy) GENDER NATIONALITY PERSON WITH DISABILITY CATEGORY STATE/UT OF PERMANENT ADDRESS

TICK THE CHECK LIST

Pasted a recent high contrast photograph? Signed(with black ballpoint pen) in the box? Signed (with black ballpoint pen) the declaration? Kept a photocopy of the filled Printed Form?

LIST OF ATTACHMENTS (TICK APPROPRIATE BOX)

Demand Draft mentioned in Application. Attested copy of SC/ST/PD/OBC(non creamy layer) Certificate(if appplicable). In case of PD Candidate, requested for Amanuensis(if applicable)? Attested copy of the affidavit for Change of Name/Surname(if applicable).

DECLARATION BY THE CANDIDATE :

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 Information Brochure and I shall abide by the terms and conditions therein. In the event of supperssion or distortion of any fact in my Application Form. I understand that I will be denied the opportunity to appear in GATE 2009. Further, if any such supperssion or distortion of facts is discovered after appearing in the examination, any admission/degree acquired on the basis of GATE 2009 score is liable for cancellation.

Place:_________________ Date:__________________
FULL SIGNATURE OF THE CANDIDATE