Instructions and Application Form for GATE 2012

Instructions for the Candidate:

1. 2. Your Login ID is ANIR14031. Remember your password and do not disclose it to anyone. There are 5 pages in this pdf file. These pages should be printed on A4 size white sheets using a laser/ink jet printer. Page - 1: Instructions for the candidate to be retained by the candidate. Page - 2 : Application Form (GATE Copy). a. Paste your recent color photo (3.5cm x 3.5cm) in the designated place. Before pasting, please write your name and application number on the backside of the photo with black ball point pen. b. Sign at the designated place. 5. 6. 7. Page - 3 : Application Form (Candidate copy) to be retained by the candidate. Page - 4 : Address page to be pasted on a 10 inch X 12 inch size laminated envelope. Page - 5 : Bank challan in triplicate. Take it to any SBI branch and pay the application fee plus the bank service charge. The Bank will retain its copy and will return the remaining two copies to you. Out of these two copies, retain the Candidate's copy with you and attach the GATE copy with the Application Form. Without folding, insert the completed Application Form (GATE copy) and attested copies of all the application documents (SC/ST/PD certificate, copy of degree certificate etc.) into a 10 inch X 12 inch laminated envelope and send by Speed Post (preferably) or by Registered Post using the address printed on page-4 so as to reach the respective Zonal GATE office on or before 24th October 2011. Application sent through courier will not be accepted.

3. 4.

8.

Put List of Documents to be attached with the Application Form:

1. 2. 3. 4. 5. 6. Application Form (GATE Copy) Bank Challan (GATE Copy) Self Attested Copy of SC/ST/PD certificate (if applicable) Self Attested Copy of affidavit for change of name (if applicable) Self Attested Copy of the degree certificate if the year of qualifying degree is 2011 or earlier. If the year of qualifying degree is 2012 or later, a certificate signed by the principal of the college clearly indicating the year of qualifying degree (format available on GATE website).

____________End of Instructions____________

APPLICATION NO. 6012069

GATE COPY

GATE 2012 APPLICATION FORM

Zone: IIT Kharagpur
1. Name of the Candidate as in the 10th Class Certificate 2. Date of Birth (DD/MM/YYYY) 3. Gender

Payment Mode: Bank Challan (SBI)

ANIRBAN KARAK 14/03/1990 MALE 9. Choice of GATE Paper 10. E-mail Address

Fee: Rs. 1000

Computer Science and Information Technology anirban.karak662@gmail.com

4. Nationality 5. Category 6. Person with Disability (PD)

INDIAN General No

11. Address for Correspondence VILLAGE PATIT P.O PATIT PS PATRASAYER DISTRICT BANKURA 12. PINCODE of Address for 722206 Correspondence 13. Year of Degree 14. Discipline 15. Name of Parent 2012 Computer Science & Engineering/Technology PRADIP KARAK West Bengal

7. Qualifying Degree

B.E./B.Tech./ B.Sc. (Engg.)/B.Sc.(Tech.)/B.Arch.

16. State/Union Territory of Permanent Residence

8. Choice of Examination City1 Choice of Examination City2

611 - Kolkata 405 - Durgapur

17. Mobile / Landline No.

09475336151

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 contents of GATE 2012 website and I shall abide by the terms and conditions therein. 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 2012. 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 2012 score is liable to be cancelled. Place : Date :

18. Signature

19. Photograph

Full Signature of the candidate using BLACK INK PEN only (do not sign in CAPITAL LETTERS)

3.5 cm x 3.5 cm

611CS6012069

Send this form along with the necessary documents to IIT Kharagpur.

APPLICATION NO. 6012069

CANDIDATE COPY

GATE 2012 APPLICATION FORM

Zone: IIT Kharagpur
1. Name of the Candidate as in the 10th Class Certificate 2. Date of Birth (DD/MM/YYYY) 3. Gender

Payment Mode: Bank Challan (SBI)

ANIRBAN KARAK 14/03/1990 MALE 9. Choice of GATE Paper 10. E-mail Address

Fee: Rs. 1000

Computer Science and Information Technology anirban.karak662@gmail.com

4. Nationality 5. Category 6. Person with Disability (PD)

INDIAN General No

11. Address for Correspondence VILLAGE PATIT P.O PATIT PS PATRASAYER DISTRICT BANKURA 12. PINCODE of Address for 722206 Correspondence 13. Year of Degree 14. Discipline 15. Name of Parent 2012 Computer Science & Engineering/Technology PRADIP KARAK West Bengal

7. Qualifying Degree

B.E./B.Tech./ B.Sc. (Engg.)/B.Sc.(Tech.)/B.Arch.

16. State/Union Territory of Permanent Residence

8. Choice of Examination City1 Choice of Examination City2

611 - Kolkata 405 - Durgapur

17. Mobile / Landline No.

09475336151

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 contents of GATE 2012 website and I shall abide by the terms and conditions therein. 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 2012. 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 2012 score is liable to be cancelled. Place : Date :

18. Signature

19. Photograph

Full Signature of the candidate using BLACK INK PEN only (do not sign in CAPITAL LETTERS)

3.5 cm x 3.5 cm

611CS6012069

Retain this copy with you for future reference.

BY SPEED / REGISTERED POST (Please do not Courier) GATE 2012 Application Form

To Chairman, GATE Indian Institute of Technology Kharagpur Kharagpur - 721302

Do not tamper with the bar code. For GATE official use.

From
ANIRBAN KARAK (APPLNO : 6012069) VILLAGE PATIT P.O PS PATIT PATRASAYER

DISTRICT BANKURA 722206

CASH VOUCHER

BANK COPY CASH VOUCHER

GATE COPY CASH VOUCHER

CANDIDATE COPY

Last date for acceptance of challan in bank : 24 October 2011.

CASH CAN BE TENDERED AT ANY SBI BRANCH GATE 2012 Application Fee Payment Challan
Use CBS Screen No. : FEE Type : Registration ID / Ref No. : Date of Birth : 8888 16 6012069 14/03/1990

Last date for acceptance of challan in bank : 24 October 2011.

CASH CAN BE TENDERED AT ANY SBI BRANCH GATE 2012 Application Fee Payment Challan
Use CBS Screen No. : FEE Type : Registration ID / Ref No. : Date of Birth : 8888 16 6012069 14/03/1990

Last date for acceptance of challan in bank : 24 October 2011.

CASH CAN BE TENDERED AT ANY SBI BRANCH GATE 2012 Application Fee Payment Challan
Use CBS Screen No. : FEE Type : Registration ID / Ref No. : Date of Birth : 8888 16 6012069 14/03/1990

Challan can be deposited minimum one day after the generation of challan.
Name of the Candidate : ANIRBAN KARAK Address for Correspondence :

Challan can be deposited minimum one day after the generation of challan.
Name of the Candidate : ANIRBAN KARAK Address for Correspondence :

Challan can be deposited minimum one day after the generation of challan.
Name of the Candidate : ANIRBAN KARAK

VILLAGE 722206

PATIT P.O

PATIT PS BANKURA -

VILLAGE 722206

PATIT P.O

PATRASAYER DISTRICT

PATRASAYER DISTRICT

PATIT PS Address for Correspondence : BANKURA -

VILLAGE 722206

PATIT P.O

PATIT PS BANKURA -

PATRASAYER DISTRICT

Mobile / Landline No: E Mail ID :

09475336151 anirban.karak662@gmail.com

Mobile / Landline No: E Mail ID :

09475336151 anirban.karak662@gmail.com

Mobile / Landline No: E Mail ID :

09475336151 anirban.karak662@gmail.com

Category : Amount : Amount in words :

General Rs.1025/- * Rupees One thousand and Twenty Five Only. (*Application Fees Including Bank Charges)

Category : Amount : Amount in words :

General Rs.1025/- * Rupees One thousand and Twenty Five Only. (*Application Fees Including Bank Charges)

Category : Amount : Amount in words :

General Rs.1025/- * Rupees One thousand and Twenty Five Only. (*Application Fees Including Bank Charges)

JOURNAL NUMBER

JOURNAL NUMBER

JOURNAL NUMBER

Signature of the Candidate/Remitter For Receiving Branch use only 1. Please note to write the Journal Number in all the challans. 2. Please feed the Application No. in REG/ID/Ref No. Column.

Signature of the Candidate/Remitter For Receiving Branch use only 1. Please note to write the Journal Number in all the challans. 2. Please feed the Application No. in REG/ID/Ref No. Column.

Signature of the Candidate/Remitter For Receiving Branch use only 1. Please note to write the Journal Number in all the challans. 2. Please feed the Application No. in REG/ID/Ref No. Column.

SEAL / DATE

AUTHORISED SIGNATORY

SEAL / DATE

AUTHORISED SIGNATORY

SEAL / DATE

AUTHORISED SIGNATORY