pplication Form for GATE 2012 ler your password and do not disclose it to anyone. 2. There are 5 pages in this pdf file. These pages should be printed on A4 size white sheets using a laserlink jet printer. 3. Page - 1: Instructions for the candidate to be retained by the candidate. 4, Page - 2 : Application Form (GATE Copy). a. Paste your recent color photo (3.5em 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. Page - 3 : Application Form (Candidate copy) to be retained by the candidate. 6. Page- 4 : Address page to be pasted on a 10 inch X 12 inch size laminated envelope. 7. 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. 8 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. Put List of Documents to be attached with the Application Form: 4. Application Form (GATE Copy) 2. Bank Challan (GATE Copy) 3. Self Attested Copy of SC/STIPD certificate (if applicable) Oo 4, Self Attested Copy of affidavit for change of name (if applicable) 5. Self Attested Copy of the degree certificate if the year of qualifying degree is 2011 or earlier. 6. Ifthe 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). 7. Candiates with backlog: copy of final semester/year marks sheet or course completion certificate or a letter from principal. End of InstructionsGATE COPY 2 APPLICATION FORM Bank Challan (SBI) Fee: Rs. 1000 (Choice of GATE Paper Gil Engineering the TOth Claes Carat 2 Dateotairh(DOMMYYY) —o2o7N 8 10.€-mal Address rameshgupta2k? gmail.com 2. Gender MALE 11. Address for Comespondance RAMES WAR GUPTA SIOKES A GUPTA, AWA AR 8 AWAN, ROOM NO-0S28 LIT. ROORKEE , UTTERAK AND. 4. Natonasty INDIAN 12. PINCODE of Acdress for 247687 Correspondence 5. Category (08CNan-Croamy Layer) 12.Yearof Degree zor 6. Person with Disbilty (PO) No 14.Discipine vive Environmenta’Stuctural Engg /Construction Engg 15.Name of Parent KES A GUPTA 7. Qualiying Degree BE IB Tech /B Sc 16.SialeUrion Tertoy of Bihar (Engg.)B.Se.(Tech.y.Arc. PPormanent Residence 8. Choice of Examination Cty! ——_—821 -Roorkee {T-Mobile Lancing No. 0 7584568 Choice of Examination Ciy2 80 = aridwar I hereby declare that all the particulars stated in this application form are true to the best of my knowledge and belief. | have read the contents of GATE 2012 website and | shall abide by the terms and conditions therein. In the event of suppression or distortion of any fact in my application form, | understand that | 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 1 Photograph Ful Signature ofthe candidate using 3.5 omx3.5 cm ‘BLACK INK PEN ony ll ll | Ua (enol sign in CAPITAL LETTERS) 82108074252 Send this form along with the necessary documents to IIT Roorkee.CANDIDATE COPY 2 APPLICATION FORM Bank Challan (SBI) Fee: Rs. 1000 (Choice of GATE Paper Gil Engineering the TOth Claes Carat 2 Dateotairh(DOMMYYY) —o2o7N 8 10.€-mal Address rameshgupta2k? gmail.com 2. Gender MALE 11. Address for Comespondance RAMES WAR GUPTA SIOKES A GUPTA, AWA AR 8 AWAN, ROOM NO-0S28 LIT. ROORKEE , UTTERAK AND. 4. Natonasty INDIAN 12. PINCODE of Acdress for 247687 Correspondence 5. Category (08CNan-Croamy Layer) 12.Yearof Degree zor 6. Person with Disbilty (PO) No 14.Discipine vive Environmenta’Stuctural Engg /Construction Engg 15.Name of Parent KES A GUPTA 7. Qualiying Degree BE IB Tech /B Sc 16.SialeUrion Tertoy of Bihar (Engg.)B.Se.(Tech.y.Arc. PPormanent Residence 8. Choice of Examination Cty! ——_—821 -Roorkee {T-Mobile Lancing No. 0 7584568 Choice of Examination Ciy2 80 = aridwar I hereby declare that all the particulars stated in this application form are true to the best of my knowledge and belief. | have read the contents of GATE 2012 website and | shall abide by the terms and conditions therein. In the event of suppression or distortion of any fact in my application form, | understand that | 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 1 Photograph Ful Signature ofthe candidate using 3.5 omx3.5 cm ‘BLACK INK PEN ony ll ll | Ua (enol sign in CAPITAL LETTERS) 82108074252 Retain this copy with you for future reference.