INDIAN STATISTICAL INSTITUTE

APPLICATION FOR ADMISSION : 2011-2012

(Read instructions carefully before filling in this form)
Form No. (R)
For Office use only

Stamp size Regn.No.

Photograph

1. Full Name (in capital letters):

2. Address for Correspondence (in capital letters):

PIN Tel.no.
(with STD code)

Mobile no. E-mail :...................................................

3. Course Code : INMO - test successfully cleared :

√
(see page 39 of the Prospectus) (put , if yes; see also pages 10 and 12 of the Prospectus)

4. Centre Code : 1st preference 2nd preference 3rd preference

5. Age : Date of Birth : day month year

√
6. Sex : Male Female (put in the appropriate box)
√
7. Marital Status : Married Unmarried (put in the appropriate box)
√
8. Caste : General SC ST OBC (put in the appropriate box)
(see Section 4, pages 7 and 8 of the Prospectus)
√
9. Physical Disability (if any) : Yes No (put in the appropriate box)
If yes, percentage of physical disability
(see Section 4, pages 7 and 8 of the Prospectus)

10. Have√you ever been admitted to a course at the Indian Statistical Institute?
(put in the appropriate box)

Yes No If yes, Course(s) .............................. Session(s) ......................................

11. Father’s Name : ............................................ Occupation : .............................

12. Mother’s Name : ............................................ Occupation : .............................

13. Guardian’s Name : ............................................ Occupation : .............................

14. If you are employed

(a) Employment Status : ............................................................................

(b) Designation : ............................................................................
(c) Employer’s Address : ............................................................................
(d) Duration : ............................................................................
(e) Experience, if any : ............................................................................
 15. (a) Academic Record: Give details of all academic examinations in which you have
passed/appeared indicating the % of marks/GPA and class in appropriate columns.
Examination√ University/ Year Subjects Total Math. Stat. Class/
(Please put in the Board (indicate Hons./ Marks Marks Marks Division
appropriate box) Major Subjects) (%)/GPA (%)/GPA (%)/GPA
Secondary/
(or equivalent)
10+2 years of
Higher Secondary
(or equivalent)

Humanities (B.A.)
Science (B.Sc.)
Commerce (B.Com.)
Engineering
(B.E./B.Tech.)
Humanities (M.A.)
Science (M.Sc.)
Commerce (M.Com.)
Engineering
(M.E./M.Tech.)
Others (specify)

(b) If INMO-test successfully cleared, then year of clearing

(for B.Stat. (Hons.) and B. Math. (Hons.) only)

(c) Whether you have a valid GATE score:Yes∗ No Appearing# in 2011

(for M.Tech. (CS) only)
If yes, then All-India rank Percentile Total marks

Subject Year
* Each such candidate must enclose, together with this Application Form, one photocopy of
his/her GATE score card containing all information mentioned in Item 15 (c).
# In addition to this Application Form being submitted, each such candidate must sub-
mit/send (i) one photocopy of his/her GATE score card containing all the information
mentioned in Item 15 (c), and (ii) one photocopy of this Application Form mentioning the
registration no. given by the Indian Statistical Institute, so as to reach the Dean of Stud-
ies by 29 April 2011. “ GATE Score for M.Tech. (CS) Applicant for 2011-12” must be
written on top of the envelope containing these documents.
(d) Academic Achievements, if any ...........................................................................
............................................................................................................................
(e) If you are due to complete the qualifying examination, give the probable dates of
(i) completion of the examination including practicals .......................................
(ii) announcement of results .......................................

16. Bank Draft No. (If you have downloaded this form) : ........................... Date: ....................

Drawn on (Bank): .......................................................

Declaration to be signed by the applicant:
The above particulars submitted by me are correct. If admitted, I shall not (a) leave in the middle of
the course, (b) violate the discipline code of the Institute, and (c) indulge in any activity hampering the
progress of my studies and spoiling the environment of the Institute.

Place : ................................. Signature of the applicant with date

Enclose the following with this Application Form :
1. Two self-addressed envelopes (not less than 10.5” X 5.5” ) without stamp. Self-address must be written
in CAPITAL LETTERS with telephone number.
2. One self-addressed Acknowledgement Card affixed with Rs. 6/-stamp, OR, one self-addressed Post
Card (only if the application form has been downloaded from the website).
The above items and the filled-in Application Form should be placed in the white envelope (supplied
with the Prospectus) and then sent to the Dean of Studies, Indian Statistical Institute, 203 B.T. Road,
Kolkata-700 108 by 28 March, 2011.