Application Form for M.Tech./M.Pharm.

Programme

Application No.: 17110680

Date & Time of Submission: 05:09PM on May 05, 2017

1. Personal Information

FULL NAME : RINKU PRASAD

MOTHER's NAME : MANJU DEVI
FATHER's NAME : AMAR NATH
Date of Birth : 1995-04-03
Email : rinkuprasadjnv345@gmail.com Gender : M
Nationality : Indian Category : SC
Physically Challenged ? :N
Mobile Number : 9621676243
Correspondence Address: village post kaneti block gorawal district sohnabhdra,up-231210
Permanent Address : village post kaneti block gorawal district sohnabhdra,up-231210
State : Uttar Pradesh

2. Application Fee Details

Application Fee : 250

E-receipt no. : DU65769827
Date of Payment : 2017-05-05

3. Programme Selection :
Student Status : Full-Time Regular
Financial Status : Institute Assistantship Required

3A. Select the Primary Programme you are applying for (Compulsory) :
Programme : M.Tech
Department/School: Department of Chemical Engineering & Technology
Discipline: Chemical Engineering
Spec 1:No Specialization
Spec 2:No Specialization
Spec 3:No Specialization
Spec 4:No Specialization
Spec 5:No Specialization
3B. Additional Programme 1 : 3C. Additional Programme 2 :
Programme : null Programme : null
Dept/School:null Dept/School: null
Discipline: null Discipline: null
Spec 1:null Spec 1:null
Spec 2:null Spec 2:null
Spec 3:null Spec 3:null
Spec 4:null Spec 4:null
Spec 5:null Spec 5:null

Spec = Specialization
4. Qualifying Entrance Examination :

Category of Examination : Gate/GPAT Qualified

Name of the Exam : GATE
Reg./Rollno. CH17S75019292
Exam discipline : CHEMICAL ENGINEERING
Exam Year : 2017
Exam Rank : 1941
Exam Score : 410
5. Academic Details :
5A. Qualifying Degree details : 5B. Other Degree details :
Degree : UG Degree Degree :
Degree Status : Appearing Degree Status :
Degree Name : BTech Degree Name :
University : HBTU University :
Discipline : CHEMICAL ENGINEERING
Discipline :
Exam Year : 2017 Exam Year :
% or CGPA : 67 % or CGPA :
5C. Intermediate (10+2):
Name of Certificate : INTERMEDIATE
Name of Board : CBSE
Subjects : PHYSICS,CHEMISTRY,MATHS,ENGLISH,HINDI
Year of Passing : 2012
Final Aggregate % or CGPA: 82.2
5D. High School (10th):
Name of Certificate : HIGH SCHOOL
Name of Board : CBSE
Subjects : ENGLISH,HINDI,MATHS,SOCIAL SCIENCE,SCIENCE
Year of Passing : 2010
Final Aggregate % or CGPA: 8.6

6. Work Experience(Mandatory if applying under sponsored category):

First Work Experience : Second Work Experience :
Period from : Period from :
Period to : Period to :
Organization : Organization :
Position : Position :

7. Declaration:
I declare that the information provided by me on this application form is correct to the
best of my knowledge and belief. I understand that any wilful misinterpretation of facts
will result in my disqualification and dismissal from the Institute if admitted.

Candidate signature

Application no.: 17110680

Date & Time of Submission: 05:09PM on May 05, 2017