ONLINE Application for GATE 2011

Instructions for the Candidate:

1. Your Login ID is SUSH16041. 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 Kanpur

List of Documents to be sent to GATE IIT Kanpur:

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 Kanpur COPY
APPLICATION FORM FOR GATE 2011
Application No: 5109961 Payment Mode: Bank Challan (State Bank of India)

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

1. Name of the Candidate as in SUSHANT BHARGAV 11. Address 39,40 VIKRAM CLASSIC
the 10th Class Certificate
RAJDEV COLONY, BERRASIA ROAD

NEAR NEW KABARKHANA

2. Date of Birth (DD/MM/YYYY) 16/04/1988

PINCODE 462001
3. Gender MALE

4. Nationality INDIAN 14. Year of Degree 2010

15. Discipline Computer Science &

5. Category General Engg./Technology
6. Person with Disability (PD) No

Do You Require a Scribe? No 16. Name of Parent D P BHARGAV

7. Qualifying Degree B.E./B.Tech./ B.Sc. 17. State/Union Territory of Madhya Pradesh

(Engg.)/B.Sc.(Tech.)/B.Arch. Permanent Residence

18. Phone / Mobile 09981814834

8. Choice of Examination City1 505 - Bhopal
Number
19. PINCODE of Address 462001
Choice of Examination City2 313 - Indore for Correspondence

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

Technology
10. E-mail Address sushant.bhargav2002@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
5109961 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 Kanpur

Page - 2
 CANDIDATE COPY
APPLICATION FORM FOR GATE 2011
Application No: 5109961 Payment Mode: Bank Challan (State Bank of India)

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

1. Name of the Candidate as in SUSHANT BHARGAV 11. Address 39,40 VIKRAM CLASSIC
the 10th Class Certificate
RAJDEV COLONY, BERRASIA ROAD

NEAR NEW KABARKHANA

2. Date of Birth (DD/MM/YYYY) 16/04/1988

PINCODE 462001
3. Gender MALE

4. Nationality INDIAN 14. Year of Degree 2010

15. Discipline Computer Science &

5. Category General Engg./Technology
6. Person with Disability (PD) No

Do You Require a Scribe? No 16. Name of Parent D P BHARGAV

7. Qualifying Degree B.E./B.Tech./ B.Sc. 17. State/Union Territory of Madhya Pradesh

(Engg.)/B.Sc.(Tech.)/B.Arch. Permanent Residence

18. Phone / Mobile 09981814834

8. Choice of Examination City1 505 - Bhopal
Number
19. PINCODE of Address 462001
Choice of Examination City2 313 - Indore for Correspondence

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

Technology
10. E-mail Address sushant.bhargav2002@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
5109961 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 505
Indian Institute of Technology Kanpur

Kanpur

From
PINCODE 2 0 8 0 1 6
SUSHANT BHARGAV

39,40 VIKRAM CLASSIC

APPLICATION NO
RAJDEV COLONY, BERRASIA ROAD

NEAR NEW KABARKHANA

5 1 0 9 9 6 1
PINCODE 4 6 2 0 0 1

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 SUSHANT BHARGAV Name of the SUSHANT BHARGAV Name of the SUSHANT BHARGAV
Present Address Present Address Present Address
39,40 VIKRAM CLASSIC RAJDEV COLONY, 39,40 VIKRAM CLASSIC RAJDEV COLONY, 39,40 VIKRAM CLASSIC RAJDEV COLONY,
BERRASIA ROAD NEAR NEW KABARKHANA BERRASIA ROAD NEAR NEW KABARKHANA BERRASIA ROAD NEAR NEW KABARKHANA
- 462001 - 462001 - 462001

Date of Birth 16/04/1988 Date of Birth 16/04/1988 Date of Birth 16/04/1988

Mobile / Landline No: 09981814834 Mobile / Landline No: 09981814834 Mobile / Landline No: 09981814834

E-mail Address: sushant.bhargav2002@gmail.com E-mail Address: sushant.bhargav2002@gmail.com E-mail Address: sushant.bhargav2002@gmail.com

Category : General Category : General Category : General

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

5109961 5109961 5109961

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

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