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INDIAN INSTITUTES OF TECHNOLOGYBOMBAY, DELHI, GUWAHATI, HYDERABAD, KANPUR, KHARAGPUR, MADRAS, ROORKEE

APPLICATION FORM FOR ADMISSION UNDER JAM 2010

To be filled by candidates qualified in JAM 2010 and desirous of Admission to Academic Programmes of IITs coveredunder JAM 2010. This Application should be sent only to Organizing Chairman, JAM 2010, IIT Madras, Chennai600 036 and should reach on or before June 7, 2010.

Hearty congratulations for qualifying in the JAM 2010 examination. As a qualified candidate in JAM 2010, you are eligibleto apply for admission to the Masters programmes provided you satisfy the minimum educational qualification(s) (MEQ)and eligibility requirement(s) (ER) as outlined in the JAM 2010 brochure. Kindly indicate your order of preferences for themasters programmes you wish to apply in the Choice Sheet in item No 9 given below. Fill all items of this application formand affix your signature in all pages of this form. Send this form along with relevant enclosures as per item No.11 and aDemand Draft of Rs. 300/- (Rupees three hundred only) drawn in favour of JAM 2010 payable at Chennai to thefollowing address by Speed Post

The Organizing Chairman, JAM 2010, IIT Madras, Chennai 600 036

1. Name of the Applicant :(in Capital Letters)

2 Registration Number in JAM 2010 :

3 Code of qualified Test Paper(s) :

4 All India Rank :

5(a) Category(Strike out which ever not applicable) GEN OBC SC ST

5(b) Person with disability (PD)(Strike out which ever not applicable) YES NO

6. Address for correspondence:

Tel. No. with STD Code: 0

0Mobile No.:

Photo of thecandidate

30 x 40 mm

Serial No.

E-mail: ____________________________________________________________________

Signature of the candidate

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7. Qualifying Examination Result (In the box to the right, write P for PASSED and A for AWAITED )

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8. Details of the academic record (attach photo copies of certificate(s) and mark sheet(s)):

ExaminationPassed

Name of Board /University

Year of Passing Subjects / Papers Taken

Aggregate*Marks (%)

10 th Standard

12 th Standard(+2 or equivalent)

BachelorsDegree**

Provide details in Table I (Ref. Page 3)

* Aggregate of all subjects, including languages and subsidiaries, for all years/ semesters of the programme

** If result is awaited, fill details up to pre-final year / semester.

Signature of the Candidate

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TABLE IMarks obtained in all papers, including languages and subsidiaries,in

Bachelors Degree for all years / semester of the programme*.

S. No. Title of Paper Marks / GradeObtained + Maximum Marks

for the Paper

I Y e a r

/ 1 s t

a n

d 2 n

d s

e m e s t e r

I I Y e a r

/ 3 r d

a n

d 4 t

h s

e m e s

t e r

I I I Y e a r

/ 5 t h

a n d 6 t

h s

e m e s

t e r

Total I = Total II =

Aggregate % of Marks = (Total I / Total II) x 100 = %

* If result is awaited, fill details up to pre-final year/ semester + For candidates with letter grade, the photocopy of mark sheet with grading scheme followed by theUniversity / Institute must be enclosed


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9. Choice Sheet: Academic programmes for JAM 2010

Registration Number in JAM 2010 :

Name of the Candidate :

Choose the eligible and interested programmes based on the paper qualified in JAM 2010. If you arequalified in more than one paper, programmes eligible for both papers are applicable to you. Mention theorder of preference (1,2,3 etc.) in the last column. The programmes that you are 'NOT Interested' mark 'X' in the order of preference column. Please note the order of preference plays an important role in theadmission process. Mention your registration numbers in all the 3 pages of this choice sheet.

Note: If you are qualified in two papers in JAM 2010, and prefer to give choice in the programmes eligible under both the papers, the order of preference should be a combined one. For example; A candidate is qualified in both BT and CY canchoose order of preference 1 under BT, 2 under CY and 3 under BT and so on.

Programmes Eligible for JAM 2010 Paper: BT

Code JAM Paper Programme Title Institute Order of Preference

104 BT M.Sc. Biotechnology (4 Semesters) IIT Bombay

108 BT M.Sc.-Ph.D. Dual Degree in Biotechnology IIT Bombay

110 BT M.Sc.-Ph.D. Dual Degree in Environmental Science &Engineering IIT Bombay

703 BT M.Sc. Biotechnology (4 Semesters) IIT Roorkee

Programme Eligible for JAM 2010 Paper: CA

Code JAM Paper Programme Title Institute Order of

Preference709 CA Master of Computer Applications (6 Semesters) IIT Roorkee

Programmes Eligible for JAM 2010 Paper: CY


105 CY M.Sc. Chemistry (4 Semesters) IIT Bombay

109 CY M.Sc.-Ph.D. Dual Degree in Energy IIT Bombay

110 CY M.Sc.-Ph.D. Dual Degree in Environmental Science & Engineering IIT Bombay

201 CY M.Sc. Chemistry (4 Semesters) IIT Delhi

301 CY M.Sc. Chemistry (4 Semesters) IIT Guwahati

401 CY M.Sc. Chemistry (4 Semesters) IIT Kanpur

501 CY Joint M.Sc.-Ph.D. Programme in Chemistry IIT Kharagpur

601 CY M.Sc. Chemistry (4 Semesters) IIT Madras

704 CY M.Sc. Chemistry (4 Semesters) IIT Roorkee

801 CY M.Sc. Chemistry (4 Semesters) IIT Hyderabad

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Registration Number in Jam 2010:

Programmes Eligible for JAM 2010 Paper: GG


101 GG M.Sc. Applied Geology (4 Semesters) IIT Bombay

502 GG Joint M.Sc.-Ph.D. Programme in Geology IIT Kharagpur

701 GG M.Sc. Applied Geology (4 Semesters) IIT Roorkee

707 GG M.Tech. Geological Technology (6 Semesters) IIT Roorkee

Programmes Eligible for JAM 2010 Paper: GP


102 GP M.Sc. Applied Geophysics (4 Semesters) IIT Bombay

503 GP Joint M.Sc.-Ph.D. Programme in Geophysics IIT Kharagpur

708 GP M.Tech. Geophysical Technology (6 Semesters) IIT Roorkee

Programmes Eligible for JAM 2010 Paper: MA


106 MA M.Sc. Mathematics (4 Semesters) IIT Bombay

109 MA M.Sc.-Ph.D. Dual Degree in Energy IIT Bombay

110 MA M.Sc.-Ph.D. Dual Degree in Environmental Science & Engineering IIT Bombay

111 MA M.Sc.-Ph.D. Dual Deg. in Operations Research IIT Bombay

202 MA M.Sc. Mathematics (4 Semesters) IIT Delhi

302 MA M.Sc. Mathematics & Computing (4 Semesters) IIT Guwahati

402 MA M.Sc. Mathematics (4 Semesters) IIT Kanpur

504 MA Joint M.Sc.-Ph.D. Programme in Mathematics IIT Kharagpur

602 MA M.Sc. Mathematics (4 Semesters) IIT Madras

702 MA M.Sc. Applied Mathematics (4 Semesters) IIT Roorkee

705 MA M.Sc. Industrial Mathematics and Informatics (4 Semesters) IIT Roorkee

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Registration Number in Jam 2010:

Programmes Eligible for JAM 2010 Paper: MS


103 MS M.Sc. Applied Statistics and Informatics (4 Semesters) IIT Bombay

111 MS M.Sc.-Ph.D. Dual Deg. in Operations Research IIT Bombay

404 MS M.Sc. Statistics (4 Semesters) IIT Kanpur

Programmes Eligible for JAM 2010 Paper: PH

Code JAM Paper Programme Title InstituteOrder of

Preference

107 PH M.Sc. Physics (4 Semesters) IIT Bombay

109 PH M.Sc.-Ph.D. Dual Degree in Energy IIT Bombay

110 PH M.Sc.-Ph.D. Dual Degree in Environmental Science & Engineering IIT Bombay

112 PH M.Sc.-Ph.D. Dual Degree in Physics IIT Bombay

203 PH M.Sc. Physics (4 Semesters) IIT Delhi

303 PH M.Sc. Physics (4 Semesters) IIT Guwahati

403 PH M.Sc. Physics (4 Semesters) IIT Kanpur

405 PH M.Sc.-Ph.D. Dual Degree in Physics IIT Kanpur

505 PH Joint M.Sc.-Ph.D. Programme in Physics IIT Kharagpur

603 PH M.Sc. Physics (4 Semesters) IIT Madras

706 PH M.Sc. Physics (4 Semesters) IIT Roorkee

Declaration

I hereby declare that the order of preference given by me for my eligible programmes is final.


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10. Details of Demand Draft of Rs. 300/- (Rupees Three Hundred Only) drawn in favour of JAM 2010 payable at Chennai.

Amount Date of issue Number Code and Name of the issuing Bank Branch

Rs. 300/-

11. Documents to be enclosed : (Attach a photocopy of each document and tick the relevant box(s))

10 th standard Certificate.

12 th standard (10+2) Certificate showing the subjects passed.

Mark sheets (including title of papers taken) for all semesters/ all the years or up to pre-final

year/semester of the qualifying degree if the result is awaited.

Category Certificate of SC/ST (if applicable), issued by a competent authority (list given in Appendix II of the JAM 2010 information Brochure).

Category Certificate of OBC (non-creamy layer) (if applicable), issued by a competent authority in theformat attached (No other format is accepted).

Certificate to support the Person with Disability (PD) status, if applicable, issued by a GovernmentMedical Board.

Please attach only photocopies. DO NOT SEND ORIGINALS.

Declaration:

I hereby declare that the particulars stated by me in this Application Form for Admission are true to the best of myknowledge and belief. Moreover, I have verified the information given above and it is found to be correct. I have read theInformation Brochure of JAM 2010 and agree to abide by the terms and conditions therein. It is entirely my responsibility to

prove my eligibility for admission to the program for which I may be admitted and also, in respects of qualification andentitlement for admission against reserved category, if claimed, to the satisfaction of the Admitting Institute. Further, in theevent of suppression or distortion of any facts such as category, educational qualifications, nationality etc. made in myoriginal Application Form of JAM 2010 as well as in this Application Form for Admission, I understand that my admission,if granted, and/or degree/ diploma acquired subsequently are liable to be cancelled/ withdrawn. I also understand that thedecision of the Organizing Institute and the Admitting Institute regarding my admission will be final and I shall abide by theordinances and regulations of the Admitting Institute in vogue from time to time. I further understand that the Order of Preferences for program(s) and corresponding Institute(s) given by me in this form are final and no alteration will bepermissible under any circumstances.

Place:

Date:

Signature of the Applicant

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INDIAN INSTITUTES OF TECHNOLOGY(Bombay, Delhi, Guwahati, Hyderabad, Kanpur, Kharagpur, Madras, Roorkee)

UNDERTAKING

To be given by a candidate whose qualifying examination result is awaited and hence is provisionally admitted

1. Name :

2. Registration Number in JAM 2010 :

3. Test Paper(s) :

4. All India Rank(s) :

I understand that my admission to any of the IITs is provisional since I have not submitted the attestedcopies of the qualifying examination certificate and/or mark sheet as per the eligibility criteria stated inSections 4 and 5 of the Information Brochure for JAM 2010.

I also understand that in the event of my failing to fulfil the eligibility criteria on or before September 30, 2010 , my provisional admission to any of the IITs will stand cancelled.

_____________________Signature of the candidate

Place : _____________________

____________________________Countersigned by Parent/ Guardian

Date : ______________________

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PHYSICAL FITNESS CERTIFICATE(To be issued by a Medical Officer in a Government Hospital)

GENERAL EXPECTATIONS

Candidates should have good general physique. In particular,a) Chest Measurement should not be less than 70 cm, with satisfactory limits of expansion and contraction.b) Vision should be normal. In case of defective vision, it should be corrected to 6/9 in both eyes or 6/6 in the

better eye.c) Hearing should be normal. Defective hearing should be corrected.d) Heart and lungs should not have any abnormality and there should be no history of mental illness or

epileptic fits.

PERSONAL HISTORY

1. Name .2. Registration Number in JAM 2010 .....

3. Parent/ Guardians Name..........

4. Date of birth: Age ( As on 01-06-2010 ) : Years ..... Months........

5. Gender.

6. Identification Mark on the Body, if any

...(This can be a mole, scar or birthmark)

7. Major illness/ operation, if any.......(Specify nature of illness/operation)

CERTIFICATE

(The following are to be filled by the Medical Officer conducting the medical examination)

1. Height ..cm 2. Weight . kg

3. Past History 4. Chest

a) Mental Disease a) Inspiration cm

b) Epileptic Fit Blood Group b) Expiration .cm

5. Blood Group .. 6. Hearing....

7. Vision with or without glasses

a) Right Eye. b) Left Eye

c) Colour Blindness d) Uniocular Vision ............

8. Respiratory system 9. Nervous system ..

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10. Heart 11. Abdomen

a) Sounds. a) Liver..

b) Murmur b) Spleen ..

12. a) Hernia .

b) Hydrocele

13. Any other defects......

Certified that.....

son / daughter of ...

a) fulfils the prescribed standard of physical fitness and is FIT for admission to IITs.

b) does not fulfil the prescribed standard of physical fitness and is unfit/ temporarily unfit foradmission due to following defects.

Signature of the Medical Officer Signature of the Candidate

Date...

Full Name.........

Medical/Registration No..

Official Seal

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JAM 2010Organizing Institute, IIT Madras

(Bombay, Delhi, Guwahati, Hyderabad, Kanpur, Kharagpur, Madras, Roorkee)

DECLARATION FORM Candidates who have been offered the academic programme of their first preference do not haveto send this form.

1. Name of the candidate :

Registration Number in JAM 2010 :

Name :

2. Name and code of the academic

programme for which admission isoffered through the first admissionlist Code :

3. Name of the Admitting Institute :

4. Would you like to be considered foryour higher preference programme(s)in the subsequent admission listsagainst vacant seats? (Please put at the appropriate box)

NoYes

I hereby declare that I have read the Information Brochure of JAM 2010 and I am fullyaware of consequences of the choice filled by me in item 4 above. As a consequence of thechoice filled by me, if I am offered admission against any of my higher preferenceprogrammes, I shall accept the newly offered programme and I am fully aware that the seatpresently offered will be automatically treated as vacant for its allotment to another eligiblecandidate. I also understand that once I am offered a seat in the higher preferenceprogramme I shall have no claim to the seat presently offered to me even if I do not join thehigher preference programme, for whatsoever reasons.

Date :

Place : Signature of the candidate

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JAM 2010Organizing Institute, IIT Madras

(Bombay, Delhi, Guwahati, Hyderabad, Kanpur, Kharagpur, Madras, Roorkee)

COURSE COMPLETION CERTIFICATE

Certified that Mr / Ms. . ...... , Roll No. ...............

final year B.Sc. / B.Sc.Ed. / B.E student of this College,

a) He / she has appeared for the final examination held during .. 2010, the results of which are awaited.

b) He / She has passed the final examination

*Strike out either (a) or (b) whichever is not applicable)

Place : Signature & Name of Principalwith Office Seal

Date :

Name of the College :

University :

___________________________________________________________________________________________________NB: Those who are appearing for qualifying examination after 15 th July 2010 are not eligible for admission even if

offer of provisional admission is issued.

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Proforma for Other Backward Class (OBC) Certificate

(CERTIFICATE TO BE PRODUCED BY OTHER BACKWARD CLASSES APPLYING FOR ADMISSIONS TOCENTRAL EDUCATIONAL INSTITUTIONS (CEIs),

UNDER THE GOVERNMENT OF INDIA)

This is to certify that Shri/Smt./Kum. ______________________________________ Son/Daughter of Shri/Smt.

______________________________ of Village/Town _____________________________ District/Division

__________________________ in the _________________________ State belongs to the ________________________

Community which is recognized as a backward class under:

(i) Resolution No. 12011/68/93-BCC(C) dated 10/09/93 published in the Gazette of India Extraordinary Part I Section I No.186 dated 13/09/93.

(ii) Resolution No. 12011/9/94-BCC dated 19/10/94 published in the Gazette of India Extraordinary Part I Section I No. 163dated 20/10/94.

(iii) Resolution No. 12011/7/95-BCC dated 24/05/95 published in the Gazette of India Extraordinary Part I Section I No. 88dated 25/05/95.

(iv) Resolution No. 12011/96/94-BCC dated 9/03/96.(v) Resolution No. 12011/44/96-BCC dated 6/12/96 published in the Gazette of India Extraordinary Part I Section I No. 210

dated 11/12/96.(vi) Resolution No. 12011/13/97-BCC dated 03/12/97.(vii) Resolution No. 12011/99/94-BCC dated 11/12/97.(viii) Resolution No. 12011/68/98-BCC dated 27/10/99.(ix) Resolution No. 12011/88/98-BCC dated 6/12/99 published in the Gazette of India Extraordinary Part I Section I No. 270

dated 06/12/99.(x) Resolution No. 12011/36/99-BCC dated 04/04/2000 published in the Gazette of India Extraordinary Part I Section I No. 71

dated 04/04/2000.(xi) Resolution No. 12011/44/99-BCC dated 21/09/2000 published in the Gazette of India Extraordinary Part I Section I No. 210

dated 21/09/2000.(xii) Resolution No. 12015/9/2000-BCC dated 06/09/2001.(xiii) Resolution No. 12011/1/2001-BCC dated 19/06/2003.(xiv) Resolution No. 12011/4/2002-BCC dated 13/01/2004.(xv) Resolution No. 12011/9/2004-BCC dated 16/01/2006 published in the Gazette of India Extraordinary Part I Section I No.

210 dated 16/01/2006.

Shri/Smt./Kum. _____________________________________ and/or his family ordinarily reside(s) in

the _______________________________ District/Division of __________________________ State.

This is also to certify that he/she does not belong to the persons/sections (Creamy Layer) mentioned in Column 3 of the Schedule to the Government of India, Department of Personnel & Training O.M. No.36012/22/93-Estt.(SCT)dated 08/09/93, modified vide OM No. 36033/3/2004 Estt.(Res.) dated 09/03/2004, or the latest notification of theGovernment of India.

This certificate is being issued based on the annual income / status of the parents / guardian of the applicant as onfinancial year ending March 31, 2009.

Dated:

District Magistrate/ Seal : Deputy Commissioner, etc.

NOTE:(a) The term Ordinarily used here will have the same meaning as in Section 20 of the Representation of the People Act,

1950.(b) The authorities competent to issue Caste Certificates are indicated below:

(i) District Magistrate / Additional Magistrate / Collector / Deputy Commissioner / Additional DeputyCommissioner / Deputy Collector / Ist Class Stipendiary Magistrate / Sub-Divisional Magistrate / TalukaMagistrate / Executive Magistrate / Extra Assistant Commissioner (not below the rank of 1 st Class StipendiaryMagistrate).

(ii) Chief Presidency Magistrate / Additional Chief Presidency Magistrate / Presidency Magistrate.(iii) Revenue Officer not below the rank of Tehsildar and(iv) Sub-Divisional Officer of the area where the candidate and / or his/her family resides.

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FORMAT OF CERTIFICATES

Certificate for SC/ST Candidates : To be issued by District Magistrate/Additional District Magistrate/Collector/DeputyCommissioner/Additional Deputy Commissioner /Deputy Collector/1st Class Stipendiary Magistrate/City Magistrate/Sub-Divisional Magistrate/Taluk Magistrate/Executive-Magistrate/Extra Assistant Commissioner/ Chief PresidencyMagistrate/Additional Chief Presidency Magistrate/Presidency Magistrate/Revenue Officer not below the rank of Thasildar/Sub-Divisinal Officer of the area where the candidate and/or his family normally resides/Administrator/ Secretaryto Administrator/Development Officer (Lakshadweep Islands).

This is to certify that Mr./Ms. . son/daughter

of .. of Village/Town . in

District/Division .. of the State/Union Territory

belongs to the . Caste/Tribe which is recognized as Scheduled Caste/ Scheduled

Tribe.

Official Seal : Signature

Name in Block Letters ..

Place & Date : Designation

Alternative Certificate

Applicable only to SC/ST persons who have migrated from one state to another for purpose of employment, education, etc.

This certificate is issued on the basis of the Scheduled Caste/Scheduled Tribe Certificate issued to

Shri/Smt .. father/mother of Shri/Smt ..... of Village/

Town . in District/Division .. of the State/ Union

Territory .... who belongs to the ... Caste/Tribe which is

recognized as a Scheduled Caste/Scheduled Tribe in the State/Union Territory .

issued by the . (name of issuing authority) vide their No.... and

dated .....

Place : Signature

Name in Block Letters ..

Date : Designation (with seal of Office)

--------------------------------------------------------------------------------------------------------------------------Please delete the words which are not applicable. True copy/photo copy attested by Headmaster of School/Gazetted Officerbe submitted

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