Beruflich Dokumente
Kultur Dokumente
3. 4.
Put
7.
____________End of Instructions____________
GATE COPY
11. Address for Correspondence 1507, BALDI KORI KI DAFAI SHEETALAMAI, EAST GHAMAPUR JABALPUR 12. PINCODE of Address for 482001 Correspondence 13. Year of Degree 14. Discipline 15. Name of Parent 2012 Computer Science & Engineering/Technology HARI SHANKER VISHWAKARMA Madhya Pradesh
7. Qualifying Degree
09993527995
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
508CS5053567
Send this form along with the necessary documents to IIT Kanpur.
CANDIDATE COPY
11. Address for Correspondence 1507, BALDI KORI KI DAFAI SHEETALAMAI, EAST GHAMAPUR JABALPUR 12. PINCODE of Address for 482001 Correspondence 13. Year of Degree 14. Discipline 15. Name of Parent 2012 Computer Science & Engineering/Technology HARI SHANKER VISHWAKARMA Madhya Pradesh
7. Qualifying Degree
09993527995
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
508CS5053567
BY SPEED / REGISTERED POST (Please do not Courier) GATE 2012 Application Form
508CS5053567
Do not tamper with the bar code. For GATE official use.
From
VIJAY KUMAR VISHWAKARMA (APPLNO : 5053567) 1507, BALDI KORI KI DAFAI SHEETALAMAI, EAST GHAMAPUR JABALPUR 482001