CLAIM FORM

Student details
Name:

Ax Latest
Passport Size

Date of Birth:

Current Mobile No.:

Photograph Here

Email:
Enrollment Details

Year of enrollment:

GATEFORUM Roll No.:

Course:

City:

Registered Email ID:

Stream:

Registered mobile Number:

Result Details

GATE Year:

Stream Appeared:

GATE Rank:

GATE Score:

GATE Marks:

Students who have opted for ME/M.Tech/MS programs for the academic year 20152016 in IISC or any IIT, both can also be
lled. please ll the Sec on I of the form and students who have been selected in a PSU please ll the Sec on II of the form.

Sec on I
1A
S.No

Name of the Ins tutes Applied

Course
Applied

Courses / Ins tute you

got a Interview / Direct Final Ins tute Selected
Admission call from

Anything more you wish to share ____________________________________________________________

_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________

2A Share your tests and interview experience at various ins tutes

Name of Ins tute

Selec on
Procedure

Pa ern of the Test

Topics Covered during Interview & Test

Interview Ques ons _____________________________________________________________________

_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
3A Please ll in the details of the Fees paid.

S.No.

Details

Semester Fees

Hostel Fees

Any other Academic

Fees Paid

JulyDec 2015
(Rs.)

JanMay 2016
(Rs.)

Sanc oned Amount

(To be lled by
GATEFORUM)

Total Fees
3B Bank & Account Details
Account Number:

Account Holders Name:

Name of the Bank:

City:

Branch:

IFSC code:

Note: Incase the Bank account provided doesnt belong to the student please men on the rela on
with the student along with his contact details
Rela on with the Student :

Mobile Number :

Sec on II
IA Share the details of PSUs you applied
S.No

Name of the PSU Applied

Posi on
Applied

PSUs you got a

Interview call from

Name of the PSU you

have been selected

Anything more you wish to share ____________________________________________________________

_______________________________________________________________________________________
_______________________________________________________________________________________
IB Share your tests and interview experience at various PSUs

Name of PSU

Selec on
Procedure

Pa ern of the Test

Group Discussion Topics

( If applicable)

Interview Ques ons _____________________________________________________________________

_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________

Scholarship Details:
Fee reimbursement for rst year of ME/M.Tech/MS programs for the academic year 20152016 in IISc or
any IIT
Fees will be reimbursed in 2 semesters; GATEFORUM will reimburse only the tui on fees and hostel fees.
One me deposits will not be reimbursed.
Students joining PSUs will be given an Android Tab
Terms & Condi ons:
1) It's mandatory for a student to give a minimum of 4 seminars/workshops in order to claim his/her
reimbursement fees in 2nd semester.
2) Its mandatory for students to ll GATEFORUM alumni network in 100pins.com.
3) Student receiving GATEFORUM Financial Scholarship will represent GATEFORUM as its brand ambassador
for his en re term with IIT's / IISc.
4) Student should have no associa on with any other GATE ins tute during their term with IIT's / IISc.
5) GATEFORUM may contact you for assignments that include teaching (in regular classroom sessions, eGATE
etc), content development and review and seminars at colleges etc.
6) Students details may be shared with Media journalist if they wish to cover any story on GATE toppers.
7) Students should not be involved in any unlawful ac vi es, both inside and outside of the campus. If any
report of such involvement comes to light, GATEFORUM reserves the right to cancel the scholarship on
disciplinary grounds.
8) Students should not try manipula ng any receipts received from IIT /IISc to claim more, incase
GATEFORUM nds any such case the scholarship will be immediately cancelled and the same shall be
informed to the concerned authori es in the campus.
9) GATEFORUM reserves the right to use student's informa on in its adver sements and promo onal
materials etc to promote its products and services.
10) GATEFORUM reserves the right to cancel the GATEFORUM scholarship program any me without any
prior no ca on.
11) In case of any dispute GATEFORUM decision is nal and no claim shall be entertained.

I cer fy that I have veried all the entries with the lledin C
F
and there is No error in it. I am fully responsible
for the errors, I have also read the terms & condi ons and agree on the same

Signature of the Student

Documents CheckList
Please scan and upload the below men oned documents (Original Copy) along with claim form
Student op ng for MTECH in IISc/IIT: 1) Fee Receipt
2) GATE Score Card
3) College Id Card
4) Admission Le er
Student op ng for PSUs:

1) Oer le er
2) Payslip
3) GATE Score Card
4) Oce ID Card