7/31/2019 103J457WApplication (3)

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1. This print out should contain the following pages.

(a) This page: Address Slip and Instructions.(b) Application form, filled with the information you provided online.(c) Bank Challan in Triplicate (available as a separate file for download from the

GATE Online Application Interface), if you have chosen Offline Challan Payment (Not applicable for female candidates).

2. On the GATE copy of the Application Form, paste a 4.5cm x 3.5cm printed copy of the SAME colorphotograph you uploaded online.(a) Use good quality glue to ensure that the photograph does not separate from the application.(b) Do not pin, stapple, sign, or attest the photograph.

3. Read the declaration and put your signature in the box next to it.

4. If you are in the final year or you have a backlog after appearing for the final year exam, you must get yourPrincipals or HODs sign and seal in the last portion of the application form. Submit the whole formto the Principals office without cutting it.

5. If you have opted for Challan payment, wait for 48 hours after your online submission to visit the banksbranch. You can visit any branch of the bank printed on your challan.

6. The bank teller will verify the details printed on the challan with the data available on their computer andthen accept the payment. The bank will retain one copy and give you back the remaining copies: one ofwhich you have to send along with the printed application form and the other is for your reference.

7. Mailing Documents to GATE office.(a) Cut the Address Slip and paste it onto an A4 sized envelope (Do not fill address by hand or tamper the

address slip).(b) Collect the supporting documents shown under Enclosure Checklist in the application form (if you

have uploaded the soft copy of the documents online, you need not send a hard copy). Mark the checklist boxes.

(c) Do NOT FOLD the application form and Do NOT STAPLE or pin the documents to the form.(d) Send the packet by Speed Post (preferably) or by Registered Post to the address mentioned. The

application packet should REACH the respective GATE office on or before Monday, 8 October 2012.

H-321

Kharagpur

IIT Kharagpur

Instructions to the Applicant (GATE 2013)

Zone/Scrutiny Code

6NPBy Registered Post/Speed Post Only

(Mobile No.)

Indian Institute of Technology Kharagpur

GATE 2013

West Bengal, 721302

To

Siddhartha Jain

Chairman GATE

95931 81373

103 J 457 W

Kharagpur, 721302

Cut Here

HJB Hall

From

Note: Application ID - 103 J 457 W. You should preserve this number for further correspondence.

7/31/2019 103J457WApplication (3)

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(Application ID)03 J 457 W

GATE 2013Zone/Scrutiny Code

Payment Details

Rs. 1200.00

6NP

D.O.B)

Scribe Assistance Required:

Qualification Details

(Exam City 1)

Siddhartha JainFull Name of Applicant)

4 Jan 1990 Male

ndian National

GEN

No

Dual Degree (after 10+2 or diploma)

Kharagpur, WB

Greater Kolkata (South), WB

CH

Navin Kumar Jain(Name of Parent)

West Bengal, 721302

West Bengal, 721302

sjiit007@gmail.com

HJB Hall

Indian Institute of Technology Kharagpur

(GATE Paper code)

Communication Address

Graduated: No, Year of Graduation: 2013

Chemical Engg.

95931 81373

hereby declare that all the particulars stated in this application form are true to the best of my knowledgend belief. I have read the Information Brochure and I shall abide by the terms and conditions therein. In thevent of suppression or distortion of any fact in my application form, I understand that I will be denied the

pportunity to appear in GATE 2013. Further, if any suppression or distortion of facts is found after appearingn the exam, any admission/degree acquired on the basis of GATE 2013 score is liable to be cancelled.

Digital Fingerprint:

Kharagpur

IIT Kharagpur

OnlineMICI2810831804

He appeared in the final semester/year exam of the above degree, but has a backlog to be clearedfrom an earlier semester/year, and therefore cannot produce a course completion certificate.

Signature of Principal/ HOD

H-321

4.5 cm x 3.5 cm

Date: Seal

(For use as the eligibility certificate only for final year or backlog applicants)

Zonal GATE Office Contact

Chairman GATEIndian Institute of Technology Kharagpur

Kharagpur, 721302

d7dd37f673b6abc26dd222008ba151a1

Applicant's recent photograph

103 J 457 W

GATE Exam Details

(Mobile No.)

(Exam City 2)

Principal Certificate

This is to certify that Siddhartha Jain is a student enrolled in

Applicants signature inside the box in black ink

17/09/2012

Date: ....../....../............

India

He is a student of the 4th/5th year of Dual Degree (after 10+2 or diploma).

Indian Institute of Technology Kharagpur, Kharagpur.

Kharagpur

Application Form

Do not AttestDo not sign on photo