ONLINE Application for GATE 2011 Instructions for the Candidate:

1. 2. 3. 4. Your Login ID is PADM1506. Remember your password and do not disclose it to anyone. There are 4 Pages in this file. These pages should be printed on A4 sheets. Page - 1: Instructions for the candidate to be retained by you carefully Page - 2 : Application Form (GATE Copy) a. Paste your recent color photo (3cm x 4cm) in designated place b. Sign at designated places 5. 6. 7. Page - 3 : Application Form (CANDIDATE Copy) to be retained by you for your reference Page - 4 : Address slip to be pasted on the A4 size envelope Insert completed Application Form (GATE Copy) and attested copies of all applicable documents (SC/ST/PD Certificate, Affidavit for change of name) into A4 size envelope, without folding and send by Speed Post (preferably) or by Registered Post to Chairman, GATE, IIT Kharagpur

List of Documents to be sent to GATE IIT Kharagpur:

1. 2. 3. Application Form (GATE Copy) Attested Copy of SC/ST/PD Certificate (if applicable) Attested Copy of affidavit for change of name (if applicable)

Page - 1

GATE IIT Kharagpur COPY APPLICATION FORM FOR GATE 2011

Application No: Zone: 6106008 Payment Mode: Application Fee: PADMA CHARAN BARAL BillDesk Gateway Rs. 800/11. Address Payment Reference No: MSDC0097730599 ROOM NO-238,SURYA BHAWAN, INDIRA GANDHI INSTITUTE OF TECHNOLOGY, SARANG 2. Date of Birth (DD/MM/YYYY) 3. Gender 4. Nationality 5. Category 6. Person with Disability (PD) Do You Require a Scribe? 7. Qualifying Degree 15/06/1989 MALE INDIAN General No No B.E./B.Tech./ B.Sc. (Engg.)/B.Sc.(Tech.)/B.Arch. 16. Name of Parent 17. State/Union Territory of Permanent Residence 18. Phone / Mobile Number 19. PINCODE of Address for Correspondence BRAJAKISHORE BARAL Orissa 14. Year of Degree 15. Discipline DIST- DHENKANAL, ORISSA PINCODE 2011 Mechanical Engg. 759146 IIT Kharagpur

1. Name of the Candidate as in the 10th Class Certificate

8. Choice of Examination City1 Choice of Examination City2 9. Choice of GATE Paper 10. E-mail Address

604 - Bhubaneswar 606 - Cuttack ME - Mechanical Engineering padma26327@gmail.com

09938764757 759146

I hereby declare that all the particulars stated in this application form are true to the best of my knowledge and belief. 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 2011. 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 2011 score is liable to be cancelled.

Place: Date:
Full Signature of the Candidate (do not sign in capital letters)

12. Photograph

6106008

13.

Full Signature of the Candidate using black ball point pen only (do not sign in capital letters)

Paste a front facial high contrast recent color photograph 3cm x 4cm without any signature or attestation

Send this form along with the necessary documents to IIT Kharagpur

Page - 2

CANDIDATE COPY APPLICATION FORM FOR GATE 2011

Application No: Zone: 6106008 Payment Mode: Application Fee: PADMA CHARAN BARAL BillDesk Gateway Rs. 800/11. Address Payment Reference No: MSDC0097730599 ROOM NO-238,SURYA BHAWAN, INDIRA GANDHI INSTITUTE OF TECHNOLOGY, SARANG 2. Date of Birth (DD/MM/YYYY) 3. Gender 4. Nationality 5. Category 6. Person with Disability (PD) Do You Require a Scribe? 7. Qualifying Degree 15/06/1989 MALE INDIAN General No No B.E./B.Tech./ B.Sc. (Engg.)/B.Sc.(Tech.)/B.Arch. 16. Name of Parent 17. State/Union Territory of Permanent Residence 18. Phone / Mobile Number 19. PINCODE of Address for Correspondence BRAJAKISHORE BARAL Orissa 14. Year of Degree 15. Discipline DIST- DHENKANAL, ORISSA PINCODE 2011 Mechanical Engg. 759146 IIT Kharagpur

1. Name of the Candidate as in the 10th Class Certificate

8. Choice of Examination City1 Choice of Examination City2 9. Choice of GATE Paper 10. E-mail Address

604 - Bhubaneswar 606 - Cuttack ME - Mechanical Engineering padma26327@gmail.com

09938764757 759146

I hereby declare that all the particulars stated in this application form are true to the best of my knowledge and belief. 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 2011. 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 2011 score is liable to be cancelled.

Place: Date:
Full Signature of the Candidate (do not sign in capital letters)

12. Photograph

6106008

13.

Full Signature of the Candidate using black ball point pen only (do not sign in capital letters)

Paste a front facial high contrast recent color photograph 3cm x 4cm without any signature or attestation

Retain this page for your reference

Page - 3

BY SPEED POST / REGISTERED POST

GATE 2011
GATE PAPER CODE EXAM CITY OF FIRST CHOICE

ME 604

To Chairman, GATE Indian Institute of Technology Kharagpur Kharagpur

From PADMA CHARAN BARAL ROOM NO-238,SURYA BHAWAN, INDIRA GANDHI INSTITUTE OF TECHNOLOGY, SARANG DIST- DHENKANAL, ORISSA PINCODE

PINCODE 7

APPLICATION NO

6 1 0 6 0
7 5 9 1 4 6

0 8

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