3. 4.
Put
7.
____________End of Instructions____________
GATE COPY
INDIAN General No
11. Address for Correspondence QUARTER NUMBER - 1/D STREET - 11 SECTOR - 8 BHILAI DIST-DURG 12. PINCODE of Address for 490009 Correspondence 13. Year of Degree 14. Discipline 15. Name of Parent 2011 Biotechnology DIGAMBER PATIL Chattisgarh
7. Qualifying Degree
09179038453
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 contents of GATE 2012 website 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 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 :
18. Signature
19. Photograph
Full Signature of the candidate using BLACK INK PEN only (do not sign in CAPITAL LETTERS)
3.5 cm x 3.5 cm
613BT6068271
Send this form along with the necessary documents to IIT Kharagpur.
CANDIDATE COPY
INDIAN General No
11. Address for Correspondence QUARTER NUMBER - 1/D STREET - 11 SECTOR - 8 BHILAI DIST-DURG 12. PINCODE of Address for 490009 Correspondence 13. Year of Degree 14. Discipline 15. Name of Parent 2011 Biotechnology DIGAMBER PATIL Chattisgarh
7. Qualifying Degree
09179038453
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 contents of GATE 2012 website 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 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 :
18. Signature
19. Photograph
Full Signature of the candidate using BLACK INK PEN only (do not sign in CAPITAL LETTERS)
3.5 cm x 3.5 cm
613BT6068271
BY SPEED / REGISTERED POST (Please do not Courier) GATE 2012 Application Form
613BT6068271
Do not tamper with the bar code. For GATE official use.
From
PRASHANT PATIL (APPLNO : 6068271) QUARTER NUMBER - 1/D STREET - 11 SECTOR - 8 BHILAI DIST-DURG 490009