APPLICATION NO.

13109992
INDIAN INSTITUTE OF TECHNOLOGY ROORKEE
APPLICATION FOR ADMISSION TO
M.TECH./M.ARCH./M.U.R.P. PROGRAMMES-2013
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CE6203011 GATE REGISTRATION NO:
1. Name of the Candidate :Phalgun M.M.V
2. Fathers Name: M.V.Satyanarayana 3. Mothers Name: P.Surya Kala
4. Date of Birth: 27-April-1991 5. Gender :
6. Nationality:
7. Category : OBC 8. Person with Different Ability:
9. Qualifying Exam Passed:
Any back paper(s)/ Supplementary(ies):
10. Percentage of Marks/CGPA: 75.000 CGPA-Point Scale/Max. Marks 100.000
11. Bachelors Degree from an IIT: If yes, Name of the IIT:
12. GATE Qualified: 13. GATE Discipline (Code): CE
14. GATE Marks Out of 100: 50.33 15. GATE Qualifying Year: 2012
16. Whether Sponsored Candidate:
(for candidates already in employement)
If Yes, Admission required :
18. Departments/Centres Applied
17. Maths at 10+2 Level:
Subject Name:
(A candidate will be required to complete and have passed/appeared the qualifying examination including
back paper(s) /supplementary(ies) examination by the date of registratrion i.e. July 17, 2013)
Likly to Clear:
Maths at Graduation Level:
Male
Indian
No
Yes
No
No
Yes
No
Yes Yes
Qualifying Degree : B.Tech.
ARD 1 CED 2 EQD 3 TSC 4
19. Codes of Academic Programme, Preference wise (As per Table-2 of Information Brochure-13)
Choices once given shall not be changed for any reason after submission of online application.
24
1
21
2
26
3
25
4
17
5
11
6
19
7
20
8
22
9
54
10
53
11
23
12
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20. Amount of Application Fee including Fee for Additional Deptts. Paid (Rs.400-700): Rs. 740.00
22. Complete Postal Address for Correspondence
50-83-2, GF-1, Sri venkateswara residency
Madhuranagar
Visakhapatnam
Andhra Pradesh
Pin Code: 530016
Email: phalgun.mmv@gmail.com
Mobile No. 9959357772
Telephone No. 08912798948
Fax No.
23. DECLARATION BY CANDIDATE
I hereby declare that all the particular stated by me in this application form are true to the best of my knowledge
and belief. I have read the Information Brochure of PG Admission-2013, IIT Roorkee given on Institute Website
and I shall abide by the terms and conditions given therein. It is entirely my responsibility, to prove my eligibility
for admission to the Programme(s) for which I am admitted and also, in respect of qualifications and entitlement
for admission against reserved category, if claimed, to the satisfaction of the Institute. Further, in the event of
suppression or distortion of any fact like category, educational qualifications, nationality, etc., made in my
application form, I understand that my admission, if granted or degree/diploma acquired subsequently, is liable
for cancellation. I also understand that the decision of IIT Roorkee regarding my admission, will be final and I
shall abide by the ordinances and regulations of IIT Roorkee, in vogue form time to time. I have read Section
8.9 of the Information Brochure regarding the institutions approach toward ragging and the punishments to
which I am liable if found guilty of ragging. Further, if admitted, I promise to abide by the statutes, ordinances
and regulations of IIT Roorkee. I further declare that I have not taken admission and registered for any
Postgraduate programme at the Institute at the level for which I am applying. I also clearly understand that I
have to complete and pass the qualifying examination including back paper (s)/supplementary(ies), if any by the
scheduled date of registration to the programme i .e. July 17, 2013. In the event I am granted admission
/registered to the programme and later on it is found that I have appeared in the examination or for a back
paper/supplementary(ies) for any subject and passed it after the date of scheduled registration to the
programme my admission /registration shall stand terminated and I will not be entitled to any claim from the IIT
Roorkee.
24. Full Signature of candidate
Place...............................
Date
Enclosures:
1. IITR Copy of Challan
2. Xerox / Downloaded copy of GATE score card
3. Copy of Final year marks sheet/Pre final year marks sheet
4. Proof of Mathematics at 10+2 or higher level marks sheet (If applicable)
5. Copy of Persons with Disability (PD) certificate (If applicable)
6. SC/ST candidates should attached caste certificates from the competent authorities. Candidates belonging
to OBC category must submit Xeroxed copy of category certificate on GOI format.Certificate should have
been issued after 31.03.2012 by a competent authority.
7. Annexure 1 / 2 / 3 / 4 / 5 as applicable.
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