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ONLINE Application for GATE 2011

Instructions for the Candidate:

1. Your Login ID is PRAC0307. Remember your password and do not disclose it to anyone.
2. There are 5 Pages in this file. These pages should be printed on A4 sheets.
3. Page - 1: Instructions for the candidate to be retained by you carefully
4. Page - 2 : Application Form (GATE Copy)
a. Paste your recent color photo (3cm x 4cm) in designated place
b. Sign at designated places
5. Page - 3 : Application Form (CANDIDATE Copy) to be retained by you for your reference
6. Page - 5 : Bank challan in triplicate. Take it to any SBI branch and pay the fee. The Bank will retain a
copy with them and will return two copies to you. In those two copies, retain the Candidate's copy with
you and attach Institute's copy with Application Form

7. Page - 4 : Address slip to be pasted on the A4 size envelope


8. Insert completed Application Form (GATE Copy) and attested copies of all applicable documents
(SC/ST/PD Certificate, Affidavit for change of name) into A4 size envelope, without folding and send by
Speed Post (preferably) or by Registered Post to Chairman, GATE, IIT Delhi

List of Documents to be sent to GATE IIT Delhi:


1. Application Form (GATE Copy)
2. Bank Challan (Institute's Copy)
3. Attested Copy of SC/ST/PD Certificate (if applicable)
4. Attested Copy of affidavit for change of name (if applicable)

Page - 1
GATE IIT Delhi COPY
APPLICATION FORM FOR GATE 2011
Application No: 3161737 Payment Mode: Bank Challan (State Bank of India)

Zone: IIT Delhi Application Fee: Rs. 800/-

1. Name of the Candidate as in PRACHI CHOUKSE 11. Address 45/4 PARDESHIPURA


the 10th Class Certificate
NR. MALAV VIDHYA MANDIR
SCHOOL
INDORE

2. Date of Birth (DD/MM/YYYY) 03/07/1989

PINCODE 452000
3. Gender FEMALE

4. Nationality INDIAN 14. Year of Degree 2009

15. Discipline Computer Science &


5. Category OBC(Non-Creamy Layer) Engg./Technology
6. Person with Disability (PD) No

Do You Require a Scribe? No 16. Name of Parent GHANSHYAM CHOUKSE

7. Qualifying Degree M.Sc./M.C.A./M.A. 17. State/Union Territory of Madhya Pradesh


Permanent Residence

18. Phone / Mobile 09926733344


8. Choice of Examination City1 313 - Indore
Number
19. PINCODE of Address 452000
Choice of Examination City2 505 - Bhopal for Correspondence

9. Choice of GATE Paper CS - Computer Science and Information


Technology
10. E-mail Address prachichoukse292@gmail.com

I hereby declare that all the particulars stated in this application form are true to the best of my knowledge and belief. 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 2011.
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 2011 score is liable to be cancelled.

Place:
Date:
Full Signature of the Candidate
(do not sign in capital letters)

12. Photograph

Paste a front
facial high
contrast recent
13. Full Signature of the Candidate color photograph
3161737 using black ball point pen only 3cm x 4cm
(do not sign in capital letters) without any
signature or
attestation

Send this form along with the necessary documents to IIT Delhi

Page - 2
CANDIDATE COPY
APPLICATION FORM FOR GATE 2011
Application No: 3161737 Payment Mode: Bank Challan (State Bank of India)

Zone: IIT Delhi Application Fee: Rs. 800/-

1. Name of the Candidate as in PRACHI CHOUKSE 11. Address 45/4 PARDESHIPURA


the 10th Class Certificate
NR. MALAV VIDHYA MANDIR
SCHOOL
INDORE

2. Date of Birth (DD/MM/YYYY) 03/07/1989

PINCODE 452000
3. Gender FEMALE

4. Nationality INDIAN 14. Year of Degree 2009

15. Discipline Computer Science &


5. Category OBC(Non-Creamy Layer) Engg./Technology
6. Person with Disability (PD) No

Do You Require a Scribe? No 16. Name of Parent GHANSHYAM CHOUKSE

7. Qualifying Degree M.Sc./M.C.A./M.A. 17. State/Union Territory of Madhya Pradesh


Permanent Residence

18. Phone / Mobile 09926733344


8. Choice of Examination City1 313 - Indore
Number
19. PINCODE of Address 452000
Choice of Examination City2 505 - Bhopal for Correspondence

9. Choice of GATE Paper CS - Computer Science and Information


Technology
10. E-mail Address prachichoukse292@gmail.com

I hereby declare that all the particulars stated in this application form are true to the best of my knowledge and belief. 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 2011.
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 2011 score is liable to be cancelled.

Place:
Date:
Full Signature of the Candidate
(do not sign in capital letters)

12. Photograph

Paste a front
facial high
contrast recent
13. Full Signature of the Candidate color photograph
3161737 using black ball point pen only 3cm x 4cm
(do not sign in capital letters) without any
signature or
attestation

Retain this page for your reference

Page - 3
BY SPEED POST / REGISTERED POST

GATE 2011
GATE PAPER CODE CS To

EXAM CITY OF FIRST Chairman, GATE


CHOICE 313
Indian Institute of Technology Delhi

Hauz Khas, New Delhi

From
PINCODE 1 1 0 0 1 6
PRACHI CHOUKSE

45/4 PARDESHIPURA
APPLICATION NO
NR. MALAV VIDHYA MANDIR SCHOOL

INDORE
3 1 6 1 7 3 7
PINCODE 4 5 2 0 0 0

Page - 4
CASH VOUCHER BANK'S COPY CASH VOUCHER INSTITUTE’S COPY CASH VOUCHER CANDIDATE'S COPY

BRANCH (CODE NO. ) BRANCH (CODE NO. ) BRANCH (CODE NO. )

GATE 2011 – Online Application Fee Payment GATE 2011 – Online Application Fee Payment GATE 2011 – Online Application Fee Payment
GATE 2011 FEE COLLECTION A/C NO. 31372883605 GATE 2011 FEE COLLECTION A/C NO. 31372883605 GATE 2011 FEE COLLECTION A/C NO. 31372883605

Name of the Candidate PRACHI CHOUKSE Name of the PRACHI CHOUKSE Name of the PRACHI CHOUKSE
Present Address Present Address Present Address
45/4 PARDESHIPURA NR. MALAV VIDHYA 45/4 PARDESHIPURA NR. MALAV VIDHYA 45/4 PARDESHIPURA NR. MALAV VIDHYA
MANDIR SCHOOL INDORE - 452000 MANDIR SCHOOL INDORE - 452000 MANDIR SCHOOL INDORE - 452000

Date of Birth 03/07/1989 Date of Birth 03/07/1989 Date of Birth 03/07/1989

Mobile / Landline No: 09926733344 Mobile / Landline No: 09926733344 Mobile / Landline No: 09926733344

E-mail Address: prachichoukse292@gmail.com E-mail Address: prachichoukse292@gmail.com E-mail Address: prachichoukse292@gmail.com

Category : OBC(Non-Creamy Layer) Category : OBC(Non-Creamy Layer) Category : OBC(Non-Creamy Layer)


Physically Disabled : No Physically Disabled : No Physically Disabled : No

Head Amount Credit to Head Amount Credit to Head Amount Credit to

Application Fees Rs. 800.00 31372883605 Application Fees Rs.800.00 31372883605 Application Fees Rs. 800.00 31372883605

Bank's Charges Rs. 30.00 98353XXXXXX Bank's Charges Rs. 30.00 98353XXXXXX Bank's Charges Rs. 30.00 98353XXXXXX

Total Rs. 830.00 Total Rs. 830.00 Total Rs. 830.00

Amount in words : Rupees eight hundred and thirty only. Amount in words : Rupees eight hundred and thirty only. Amount in words : Rupees eight hundred and thirty only.

Signature of the Candidate/Remitter Signature of the Candidate/Remitter Signature of the Candidate/Remitter


For Receiving Branch use only For Receiving Branch use only For Receiving Branch use only

APPLICATION NUMBER JOURNAL NUMBER APPLICATION NUMBER JOURNAL NUMBER APPLICATION NUMBER JOURNAL NUMBER

3161737 3161737 3161737

1. Please credit Rs.30/- to your Branch Commission 1. Please credit Rs.30/- to your Branch Commission 1. Please credit Rs.30/- to your Branch Commission
A/c No.98353XXXXXX A/c No.98353XXXXXX A/c No.98353XXXXXX
2. Please note to write the Journal Number in all the challans. 2. Please note to write the Journal Number in all the challans. 2. Please note to write the Journal Number in all the challans.
3. Please feed the Application No. in REG/ID/Ref No. Column 3. Please feed the Application No. in REG/ID/Ref No. Column 3. Please feed the Application No. in REG/ID/Ref No. Column
and Name of the Candidate in the menu while posting. and Name of the Candidate in the menu while posting. and Name of the Candidate in the menu while posting.

SEAL / DATE AUTHORISED SIGNATORY SEAL / DATE AUTHORISED SIGNATORY SEAL / DATE AUTHORISED SIGNATORY

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