SUBMITTED ON : INDIAN INSTITUTE OF TECHNOLOGY KHARAGPUR ORGANISING INSTITUTE: INDIAN INSTITUTE OF TECHNOLOGY ROORKEE

ONLINE APPLICATION FORM FOR GATE 2009

COMPLETE MAILING ADDRESS INCLUDING NAME PHOTOGRAPH
NAME: RUPAYAN GHOSH PASTE (DO NOT STAPLE)
ADDRESS: A RECENT FRONT
Vill:kalitala FACIAL HIGH CONTRAST
P.O:Debipur(R.S.) PHOTOGRAPH OF SIZE
Dist: Burdwan 3 CM X 4 CM. Photograph
West Bengal must not be larger than this
PIN CODE: 713146 box or else the application is
Email Address: cool_rupayan@rediffmail.com liable to be rejected. Do not 663620
get the photograph attested

FULL SIGNATURE WITH BLACK BALLPOINT PEN

INFORMATION TO THE CANDIDATE: On the printed form, paste your PHOTOGRAPH and SIGN at the two specified places. Keep a photcopy of the form and the demand
draft. Send the compeleted form along with the Demand Draft, a copy of the SC/ST/OBC (Non Creamy Layer)/PD certificate, (if applicable) to the CHAIRMAN, GATE, of the
corrsponding zone (website of which has been used) by Speed/Registered Post.

APPLICATION NUMBER : 663620 DEMAND DRAFT DETAILS

NAME OF THE CANDIDATE : RUPAYAN GHOSH BANK NAME : UCO BANK
EXAMINATION CITY CODE (1st Choice) : Kolkata (611) BANK ID(MICRO NO) : 000028000
EXAMINATION CITY CODE (2nd Choice) : Kharagpur (610) DEMAND DRAFT NUMBER : 171560
DATE OF ONLINE SUBMISSION (dd/mm/yy) : 22/10/08 AMOUNT : Rs. 900.00 Only
DATE OF ISSUE (dd/mm/yy) : 22/10/08

OTHER DETAILS :
NAME OF PARENT : DEBI PRASAD GHOSH GATE PAPER CODE : CS
DATE OF BIRTH (dd/mm/yy) : 04/01/88 QUALIFYING DEGREE : E
GENDER : Male QUALIFYING YEAR : 2009
NATIONALITY : Indian DISCIPLINE CODE : 14
PERSON WITH DISABILITY : NO COLLEGE CODE : WB001
CATEGORY :G PIN CODE OF COLLEGE : 712121
STATE/UT OF PERMANENT ADDRESS : West Bengal (WB) MOBILE/LANDLINE PHONE : 0342-2263090

TICK THE CHECK LIST LIST OF ATTACHMENTS (TICK APPROPRIATE BOX)

Pasted a recent high contrast photograph? Demand Draft mentioned in Application.

Signed(with black ballpoint pen) in the box? Attested copy of SC/ST/PD/OBC(non creamy layer) Certificate(if appplicable).

Signed (with black ballpoint pen) the declaration? In case of PD Candidate, requested for Amanuensis(if applicable)?

Kept a photocopy of the filled Printed Form? Attested copy of the affidavit for Change of Name/Surname(if applicable).

DECLARATION BY THE CANDIDATE :

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 Information
Brochure and I shall abide by the terms and conditions therein. In the event of supperssion or distortion of any fact in my Application Form. I
understand that I will be denied the opportunity to appear in GATE 2009. Further, if any such supperssion or distortion of facts is discovered after appearing
in the examination, any admission/degree acquired on the basis of GATE 2009 score is liable for cancellation.

Place:_________________

Date:__________________
FULL SIGNATURE OF THE CANDIDATE