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13/04/2017 ApplicationForm

IndianInstituteofTechnologyGuwahati
ApplicationFormforAdmissiontoMAProgramme

1.ApplicationNumber: 111

2.ApplicantName: RAJANISHTRIPATHI

3.Gender: MALE

4.Father/GuardianName: SHAMBHUNATHTRIPATHI

5.DateofBirth: 19960715
6.MaritalStatus: SINGLE Applicant'sPhoto
7.Nationality: Indian
8.CasteCategory: General
9.PhysicallyDisable: NO
10.StudentCategory: REGULAR(FULLTIME)
11.AnyQualifyingdegreefromIIT's NO

12.CorrespondenceAddress: VILLAGETIWARIPURPOSAJOIPSJANSA
Vill./Town/City:VARANASI
State:UttarPradesh
Pincode:221302
STDcode:
TelephoneNumber:
FaxNumber:
Email:rajanish115@gmail.com
MobileNumber:8601136901

13.PermanentAddress:
VILLAGETIWARIPURPOSAJOIPSJANSA
Vill./Town/City:VARANASI
State:UttarPradesh
Pincode:221302
STDcode:
TelephoneNumber:
FaxNumber:
Email:rajanish115@gmail.com
MobileNumber:8601136901

14.Applicant'sChoices:
Departmentapplied AreaOfInterests
1.HumanitiesandSocialSciences 1.HumanitiesandSocialSciences

15.AcademicRecord:

SlNo. ExamName Board/University %/CGPA/CPI Grade SubjectsTaken Yearof Status


Format Passing
Class10thOR %outof ENGLISHSANSKRIT
1. UPBOARD 79 HINDIMATHSSOCIAL 2011 Passed
Equi. 100
SCIENCESCIENCE
Class12thOR %outof ENGLISHHINDIMATHS 2013
2. UPBOARD 82.4 Passed
Equi. 100 PHYSICSCHEMISTRY
B.A.HONS. POLITICALSCIENCE
BANARASHINDU CGPAout
3. POLITICAL UNIVERSITY 8.04 of10 SOCIOLOGY 2017 Appeared
SCIENCE PSYCHOLOGY

16.ProfessionalExperience:
SlNo. NameOfOrganization PositionHeld TypeOfwork StartDate EndDate


17.DemandDraft:
DemandDraft[(Rs.150/forGen/OBCcandidates)and(Rs.75/forSC/ST/PDcandidates)]willberequiredatthetimeofWrittenTestand/or
Interview,ifcalledfor.Pleaseseedetailsaboutitin'ApplicationProcedure'.
https://auto.iitg.ernet.in/ma/print_application_details.jsp?rollno=111 1/2
13/04/2017 ApplicationForm
Interview,ifcalledfor.Pleaseseedetailsaboutitin'ApplicationProcedure'.


18.ListofEnclosures:
UploadedLastQualifyingExaminationMarksheet.
AttestedcopiesofallsupportingdocumentswillberequiredatthetimeofWrittenTestand/orInterview,ifcalledfor.Pleaseseedetailsaboutit
in'ApplicationProcedure'.


Declaration

Iherebydeclarethattheentriesmadeinthisapplicationformarecorrecttothebestofmyknowledgeandbelief.Ifselectedforadmission,I
promisetoabidebytherulesandregulationsoftheInstitute.

InotethatthedecisionoftheInstituteisfinalinregardtoselectionforadmissionandassignmenttoaparticularDepartment/Centreand
fieldofstudy.TheInstituteshallhavetherighttotakeanyactionitdeemsfit,includingexpulsion,againstmeatanytimeaftermyadmission,ifit
isfoundthatanyinformationfurnishedbymeisincorrect.

Place:
Date: Signature

2017IITGOfficeAutomation|IITGuwahati

https://auto.iitg.ernet.in/ma/print_application_details.jsp?rollno=111 2/2

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