Zone/Scrutiny Code

By Registered Post/Speed Post Only

6NP
To

GATE 2013
Chairman GATE Indian Institute of Technology Kharagpur Kharagpur, 721302

From Siddhartha Jain

H-321 HJB Hall IIT Kharagpur Kharagpur West Bengal, 721302

103 J 457 W

95931 81373

(Mobile No.)

Cut Here

Instructions to the Applicant (GATE 2013)

1. This print out should contain the following pages. (a) This page: Address Slip and Instructions. (b) Application form, filled with the information you provided online. (c) Bank Challan in Triplicate (available as a separate file for download from the GATE Online Application Interface), if you have chosen Offline Challan Payment (Not applicable for female candidates). 2. On the GATE copy of the Application Form, paste a 4.5cm x 3.5cm printed copy of the SAME color photograph you uploaded online. (a) Use good quality glue to ensure that the photograph does not separate from the application. (b) Do not pin, stapple, sign, or attest the photograph. 3. Read the declaration and put your signature in the box next to it. 4. If you are in the final year or you have a backlog after appearing for the final year exam, you must get your Principals or HODs sign and seal in the last portion of the application form. Submit the whole form to the Principals office without cutting it. 5. If you have opted for Challan payment, wait for 48 hours after your online submission to visit the banks branch. You can visit any branch of the bank printed on your challan. 6. The bank teller will verify the details printed on the challan with the data available on their computer and then accept the payment. The bank will retain one copy and give you back the remaining copies: one of which you have to send along with the printed application form and the other is for your reference. 7. Mailing Documents to GATE office. (a) Cut the Address Slip and paste it onto an A4 sized envelope (Do not fill address by hand or tamper the address slip). (b) Collect the supporting documents shown under Enclosure Checklist in the application form (if you have uploaded the soft copy of the documents online, you need not send a hard copy). Mark the check list boxes. (c) Do NOT FOLD the application form and Do NOT STAPLE or pin the documents to the form. (d) Send the packet by Speed Post (preferably) or by Registered Post to the address mentioned. The application packet should REACH the respective GATE office on or before Monday, 8 October 2012.

Note: Application ID - 103 J 457 W. You should preserve this number for further correspondence.

Zone/Scrutiny Code

6NP
103 J 457 W
(Full Name of Applicant)

GATE 2013 Application Form

Applicant's recent photograph

4.5 cm x 3.5 cm

(Application ID)

Siddhartha Jain 103 J 457 W

14 Jan 1990
(D.O.B)

Male
(Name of Parent)

GEN

Do not Attest Do not sign on photo

Indian National

Navin Kumar Jain

Communication Address
H-321 HJB Hall IIT Kharagpur Kharagpur West Bengal, 721302 India

GATE Exam Details

CH
(GATE Paper code)

Kharagpur, WB
(Exam City 1)

Greater Kolkata (South), WB

(Exam City 2) Scribe Assistance Required:

sjiit007@gmail.com 95931 81373 (Mobile No.)

No

Qualification Details
Dual Degree (after 10+2 or diploma) Chemical Engg. Graduated: No, Year of Graduation: 2013 Indian Institute of Technology Kharagpur Kharagpur West Bengal, 721302

Zonal GATE Office Contact

Chairman GATE Indian Institute of Technology Kharagpur Kharagpur, 721302

Payment Details

Online

Rs. 1200.00

MICI2810831804 17/09/2012
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 suppression or distortion of any fact in my application form, I understand that I will be denied the opportunity to appear in GATE 2013. Further, if any suppression or distortion of facts is found after appearing in the exam, any admission/degree acquired on the basis of GATE 2013 score is liable to be cancelled.

Digital Fingerprint: d7dd37f673b6abc26dd222008ba151a1

Date: ....../....../............

Applicants signature inside the box in black ink

Principal Certificate

(For use as the eligibility certificate only for final year or backlog applicants)

This is to certify that Siddhartha Jain is a student enrolled in Indian Institute of Technology Kharagpur, Kharagpur. He is a student of the 4th/5th year of Dual Degree (after 10+2 or diploma). He appeared in the final semester/year exam of the above degree, but has a backlog to be cleared from an earlier semester/year, and therefore cannot produce a course completion certificate.

Date:

Signature of Principal/ HOD

Seal