CEED 2012 Indian Institute of Technology, Bombay

Date of Examination: Sunday, December 4, 2011

Application Form
Application Number: 20122426 Name of the Applicant: GANESHPERUMAL.V

Date of Birth: 30-9-1990 Category: OBC

Gender: Male
Nationality: Indian Person With Disability: No Choice of Examination Center: Applicant's Mobile/Phone No: Qualifying Degree/Diploma: Month and Year of Passing: Institute Attended for Degree/Diploma: Complete Mailing Address of the Applicant: Chennai 08144108818 /0427-2465332 Bachelor's Degree in Engg./Arch./Design 4-2012 infant jesus college of engineering GANESHPERUMAL.V 39/26, seerangan street no:4,dadagapatty, salem PIN-636006 Mode of Payment: SBI Cash Voucher Bank : State Bank of India Amount: Rs. 950.00 Enclosures SBI Cash Voucher/Demand Draft with details Attested copy of SC/ST/OBC Certificate from appropriate authority (if applicable) Attested copy of Disability Certificate from appropriate medical authority (if applicable) Attested copy of experience certificate (for GD Art Qualified applicants) Declaration by the Applicant:
I hereby declare that the particulars furnished by me in this application form are correct to the best of my knowledge. I understand that the authorities may invalidate my CEED application/qualification at any time, if I have furnished false information.

Date:...................................................... Place:...................................................... Signature:......................................................

Instructions for filling and submission of Application Printout

1. Complete the Application Printout, following the instructions given below.
A. B. C. Signature of the Applicant: Put your signature in black pen within the box. Signature in the form of ALL CAPITAL LETTERS will NOT be considered as a valid signature. Photograph: Paste a good contrast photograph of 3cm width x 4cm height within the box. Do not staple the photograph since it will be scanned. Do NOT sign on the photograph. Do NOT get it attested. Declaration by the Applicant: Read the statement and put your signature within the box. Both the signatures on the Application Printout MUST be identical. Signature in the form of ALL CAPITAL LETTERS will NOT be considered as a valid signature. Enclosures: Tick in the appropriate box(es) and attach the relevant certificate(s) from the appropriate authority.

D.

2. The completed Application Printout, along with IITB Copy of the SBI Cash Voucher OR the Demand Draft (write your name and application number on the back of the DD), and other enclosures (if any), are to be submitted in an envelope to GATE Office IIT Bombay on or before Friday, October 14, 2011. 3. Write CEED 2012 Application on top of the envelope. 4.The Envelope can be submitted in person at the counter of GATE Office, IIT Bombay or mailed only by Registered Post or Speed Post to "GATE Office, IIT Bombay, Powai, MUMBAI 400 076"

Please note:
Applications complete in all the above respects, will only be considered. Before sending the documents the candidates are advised to take a Photo copy of all the materials for their reference.

Check List for mailing the Application Printout:

Duly completed Application Printout Two identical signatures on the Application Printout Photograph pasted on the Application Printout IITB copy of SBI Cash Voucher / Demand Draft Attested copy of SC/ST/OBC (non-creamy layer) certificate attached (if applicable) Attested copy of disability certificate attached (if applicable) Attested copy of experience certificate (for GD Art qualified applicant)

For your future reference, retain a copy of your Application Printout or note down the following information::
Application No. Applicant's name as in the Application Printout Date of Application Printout posting Choice of Examination Centre Mode of Payment

For any query, quote your Application No. (NOT User ID) and choice of Examination Centre

SBI CASH VOUCHER (BANK COPY)

SBI CASH VOUCHER (IIT B COPY)

STATE BANK OF INDIA Application Fee Details For CEED 2012 - IIT BOMBAY ISFC Code:SBIN0001109 A/C No: 31361402904 SBI Branch code:01109 Place: IIT Powai, Mumbai 400076
Candidate's Name: GANESHPERUMAL.V Application Number: 20122426 User ID: CW1632426 Category: OBC Application Fee: 950.00 (Rupees Nine hundred and fifty only) Bank Charges: Rs.25/Date Signature of the candidate

STATE BANK OF INDIA Application Fee Details For CEED 2012 - IIT BOMBAY ISFC Code:SBIN0001109 A/C No: 31361402904 SBI Branch code:01109 Place: IIT Powai, Mumbai 400076
Candidate's Name: GANESHPERUMAL.V Application Number: 20122426 User ID: CW1632426 Category: OBC Application Fee: 950.00 (Rupees Nine hundred and fifty only) Bank Charges: Rs.25/Date Signature of the candidate

(To be filled by the Bank) An amount of Rs .....................as mentioned above has been received.(Fee receiving branch is advised to write the Deposit Journal No and Branch Code No invariably) SBI Branch Name: Branch Code No: Journal No: Deposit Date:

(To be filled by the Bank) An amount of Rs .....................as mentioned above has been received.(Fee receiving branch is advised to write the Deposit Journal No and Branch Code No invariably) SBI Branch Name: Branch Code No: Journal No: Deposit Date:

Authorised signatory with Stamp

Authorised signatory with Stamp