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GATE COPY
11. Address for Correspondence PLOT NO 22 INDIRANAGAR COLONY EXTENSION NEAR ABHYUDAYA DEGREE COLLEGE SRIKAKULAM 12. PINCODE of Address for 532001 Correspondence 13. Year of Degree 14. Discipline 2012 Electronics & Comm./Electronics Engg./Communication Engg./Telecommunication Engg VENKATA RAMANA Andhra Pradesh
15. Name of Parent 7. Qualifying Degree B.E./B.Tech./ B.Sc. (Engg.)/B.Sc.(Tech.)/B.Arch. 16. State/Union Territory of Permanent Residence
08942220752
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
618EC6028502
Send this form along with the necessary documents to IIT Kharagpur.
CANDIDATE COPY
11. Address for Correspondence PLOT NO 22 INDIRANAGAR COLONY EXTENSION NEAR ABHYUDAYA DEGREE COLLEGE SRIKAKULAM 12. PINCODE of Address for 532001 Correspondence 13. Year of Degree 14. Discipline 2012 Electronics & Comm./Electronics Engg./Communication Engg./Telecommunication Engg VENKATA RAMANA Andhra Pradesh
15. Name of Parent 7. Qualifying Degree B.E./B.Tech./ B.Sc. (Engg.)/B.Sc.(Tech.)/B.Arch. 16. State/Union Territory of Permanent Residence
08942220752
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
618EC6028502
BY SPEED / REGISTERED POST (Please do not Courier) GATE 2012 Application Form
618EC6028502
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MIRIAPPALLI SANTOSHI (APPLNO : 6028502) PLOT NO 22 INDIRANAGAR COLONY EXTENSION NEAR ABHYUDAYA DEGREE COLLEGE SRIKAKULAM 532001
Date of Deposit : DD/MM/YY (to be treated by Applicant as fee receipt) Account to be Credited : 0036SLFEECOL
Date of Deposit : DD/MM/YY (to be treated by Applicant as fee receipt) Account to be Credited : 0036SLFEECOL
Account to be Credited :
0036SLFEECOL
1.Institution Name : 2.Student/Applicant Name : 3.Roll No/Application No : 4.Class/DOB : 5.Section/Category : 6.Amount : 7.Amount in words : 8.Cash Details : Denomination 1000 X 500 X 100 X
1.Institution Name : 2.Student/Applicant Name : 3.Roll No/Application ID : 4.Class/DOB : 5.Section/Category : 6.Amount : 7.Amount in words : 8.Cash Details : Denomination 1000 X 500 X 100 X
1.Institution Name : 2.Student/Applicant Name : 3.Roll No/Application ID : 4.Class/DOB : 5.Section/Category : 6.Amount : 7.Amount in words : 8.Cash Details : Denomination 1000 X 500 X 100 X
6028502
6028502
6028502
30/08/91 NA Rs.1025/- * Rupees One thousand and Twenty Five Only. (*Including Rs. 25 as Bank Charge)
30/08/91 NA Rs.1025/- * Rupees One thousand and Twenty Five Only. (*Including Rs. 25 as Bank Charge)
30/08/91 NA Rs.1025/- * Rupees One thousand and Twenty Five Only. (*Including Rs. 25 as Bank Charge)