APPLICATION SLIP

--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Application no.

: NAL0018598

Applied date

: 11/01/2013

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PERSONAL DETAILS :
1. Registration number of GATE2013

: 86211195

9. Ex-Servicemen

: No

2. Name of the discipline

: Civil

10. Nationality (Indian)

: Yes

3. Name of applicant

: VISHAL KUMAR GAUTAM

11. Religion

: Hindu

4. Father's name

: DILIP KUMAR GAUTAM

12. Gender

: Male

5. Date of birth

: 09/01/1989

13. Marital status

: Unmarried

: No

14. Are you an departmental

candidate

: No

6. Age relaxation claimed

Personal No(SAP) :
Department

, Designation :
, Unit

7. Domicile of J&K between

01/01/1980 to 31/12/1989

: No

15. (a) Indicate if you belong to

PWD category

: No

8. Victims of 1984 riot category

: No

(b) % of disablity minimum 40%

16. Category

: Scheduled Caste(SC)

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CONTACT DETAILS :
17. Address for communication :
Plot No./House No.

: VILL- DANDUPUR

Street No.

: SORAM

At/Po

: SEWAITH

Via

: ALLAHABAD

City

: ALLAHABAD

State

: Uttar Pradesh

Pin

: 211013
Alternative Mobile No.

18. Contact details

Mobile No.

: 8556967320

Landline No.

19. Email Id

: gautamvishal090189@gmail.com 20. Alternative Email Id

21. Permanent address

(Other than address of communication)
Plot No/House No.

: VILL- DANDUPUR

Street No.

: SORAM

At/Po

: SEWAITH

Via

: ALLAHABAD

City

: ALLAHABAD

State

: Uttar Pradesh

Pin

: 211013
Station City

: ALLAHABAD

22. Nearest railway station

Station Name

: ALLAHABADJN

Station State

: Uttar Pradesh

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QUALIFICATION DETAILS :
Discipline

: Civil

Name of the degree

: B.Tech

Degree In

: Civil Engineerings

Examination
Passed/Appeared/Appearing

: Passed

Name of the University/Institute

: GBTU LUCKNOW

The course is recognized by

: AICTE

Type of course

: Regular

Month of passing

: 5

: 2012

% of marks up to 2 decimal places in

: 66.03
aggregate

Year of passing

Higher qualification if Any:No

Higher Qualification Details
E x a m i n a t i o n
passed/appeared/appearin
g

Name of the
University/Institute

Discipline

Name of the degree

Degree In

NA

NA

NA

NA

NA

The course is recognized by

Type of Course

Month of passing

Year of passing

% of marks up to 2 decimal
places in aggregate

NA

NA

NA

NA

NA

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DECLARATION :
I do hereby declare that all statements/information made in the application are true, complete and correct to the best of my knowledge and belief. In
case it is detected at any stage of recruitment/selection/even after appointment that I do not fulfill the eligibility norms and/or that I have furnished
any incorrect/false information or has suppressed any materials fact(s), my candidature/appointment will automatically stand cancelled, as the
candidature/appointment would be deemed to be void ab initio.I understand that my Candidature will be provisionally considered if this application
form duly completed in all respect along with up loading of pass port size photograph, digital signature, GATE admit card, qualification
certificate/mark sheet as and where applicable.

Notes :
1. Please keep a photocopy of the application slip for future reference.
2. A print out of this application slip is to be submitted at the time of personal interview if shortlisted.