7.

Page - 4 : Address page to be pasted on a 10 inch X 12 inch size laminated envelope.

Instructions for the Candidate:

1.

2.

Page - 1: Instructions for the candidate to be retained by the candidate.3.

4.

5.

a. Paste your recent color photo (3.5cm x 3.5cm) in the designated place. Before pasting, please writeyour name and application number on the backside of the photo with black ball point pen.

6.

There are 4 pages in this pdf file. These pages should be printed on A4 size white sheets using alaser/ink jet printer.

Page - 2 : Application Form (GATE Copy).

Page - 3 : Application Form (Candidate copy) to be retained by the candidate.

Instructions and Application Form for GATE 2012

1. Application Form (GATE Copy)

2. Self Attested Copy of SC/ST/PD certificate (if applicable)

3. Self Attested Copy of affidavit for change of name (if applicable)

Your Login ID is SACH200815. Remember your password and do not disclose it to anyone.

Without folding, insert the completed Application Form (GATE copy) and attested copies of all theapplication documents (SC/ST/PD certificate, copy of degree certificate etc.) into a 10 inch X 12 inchlaminated envelope and send by Speed Post (preferably) or by Registered Post using the addressprinted on page-4 so as to reach the respective Zonal GATE office on or before 24th October 2011.

List of Documents to be attached with the Application Form:

4. Self Attested Copy of the degree certificate if the year of qualifyingdegree is 2011 or earlier.

5. If the year of qualifying degree is 2012 or later, a certificate signed bythe principal of the college clearly indicating the year of qualifyingdegree (format available on GATE website).

____________End of Instructions____________

Application sent through courier will not be accepted.

Put

b. Sign at the designated place.

7. Candiates with backlog: copy of final semester /year marks sheet orcourse completion certificate or a letter from principal.

Computer Science and InformationTechnology

SACHCHIDA NAND SINGHName of the Candidate as inthe 10th Class Certificate

Choice of GATE Paper1. 9.

GATE COPYAPPLICATION NO. 8066815

GATE 2012 APPLICATION FORM

Zone: IIT Roorkee Payment Mode: Payment GatewayPayment Reference No: MSBI1005445686

Fee: Rs. 1000

Date of Birth (DD/MM/YYYY)2. E-mail Address sssach05@gmail.com20/08/1989 10.

Gender3. MALE Address for Correspondence VILL.-DOBHIYARA11.POST-DOBHIYARADIST.-SULTANPUR

Category

Person with Disability (PD)

Nationality

Year of Degree

Discipline

5.

6.

4.

13.

14.

General

No

INDIAN

2012

Computer Science &Engineering/Technology

PINCODE of Address forCorrespondence

12. 227815

Qualifying Degree

Choice of Examination City1

Choice of Examination City2

Name of Parent

State/Union Territory ofPermanent Residence

7.

8.

15.

16.B.E./B.Tech./ B.Sc.(Engg.)/B.Sc.(Tech.)/B.Arch.

815 - Mathura

501 - Agra

JAG JIWAN SINGH

Uttar Pradesh

I hereby declare that all the particulars stated in this application form are true to the best of my knowledge andbelief. I have read the contents of GATE 2012 website and I shall abide by the terms and conditions therein. Inthe event of suppression or distortion of any fact in my application form, I understand that I will be denied theopportunity to appear in GATE 2012. Further, if any such suppression or distortion of facts is found afterappearing in the exam, any admission/degree acquired on the basis of GATE 2012 score is liable to becancelled.

Mobile / Landline No.17. 09897068420

Place :

Date :

Full Signature of the candidate usingBLACK INK PEN only

(do not sign in CAPITAL LETTERS)

815CS8066815

19. Photograph18. Signature

3.5 cm x 3.5 cm

Send this form along with the necessary documents to IIT Roorkee.

Computer Science and InformationTechnology

SACHCHIDA NAND SINGHName of the Candidate as inthe 10th Class Certificate

Choice of GATE Paper1. 9.

CANDIDATE COPYAPPLICATION NO. 8066815

GATE 2012 APPLICATION FORM

Zone: IIT Roorkee Payment Mode: Payment GatewayPayment Reference No: MSBI1005445686

Fee: Rs. 1000

Date of Birth (DD/MM/YYYY)2. E-mail Address sssach05@gmail.com20/08/1989 10.

Gender3. MALE Address for Correspondence VILL.-DOBHIYARA11.POST-DOBHIYARADIST.-SULTANPUR

Category

Person with Disability (PD)

Nationality

Year of Degree

Discipline

5.

6.

4.

13.

14.

General

No

INDIAN

2012

Computer Science &Engineering/Technology

PINCODE of Address forCorrespondence

12. 227815

Qualifying Degree

Choice of Examination City1

Choice of Examination City2

Name of Parent

State/Union Territory ofPermanent Residence

7.

8.

15.

16.B.E./B.Tech./ B.Sc.(Engg.)/B.Sc.(Tech.)/B.Arch.

815 - Mathura

501 - Agra

JAG JIWAN SINGH

Uttar Pradesh

I hereby declare that all the particulars stated in this application form are true to the best of my knowledge andbelief. I have read the contents of GATE 2012 website and I shall abide by the terms and conditions therein. Inthe event of suppression or distortion of any fact in my application form, I understand that I will be denied theopportunity to appear in GATE 2012. Further, if any such suppression or distortion of facts is found afterappearing in the exam, any admission/degree acquired on the basis of GATE 2012 score is liable to becancelled.

Mobile / Landline No.17. 09897068420

Place :

Date :

Full Signature of the candidate usingBLACK INK PEN only

(do not sign in CAPITAL LETTERS)

815CS8066815

19. Photograph18. Signature

3.5 cm x 3.5 cm

Retain this copy with you for future reference.

To

BY SPEED / REGISTERED POST(Please do not Courier)

Chairman, GATE

GATE 2012 Application Form

Indian Institute of Technology Roorkee

FromSACHCHIDA NAND SINGH (APPLNO : 8066815)

VILL.-DOBHIYARA

Roorkee - 247667

Do not tamper with the bar code. For GATE official use.

815CS8066815

POST-DOBHIYARA

DIST.-SULTANPUR

227815