8/3/2019 GATE2012_5020208

1/4

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

Your Login ID is SHAL1911. 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

Application sent through courier will not be accepted.

Put

b. Sign at the designated place.

8/3/2019 GATE2012_5020208

2/4

List of Documents to be attached with the Application Form: Put

Computer Science and InformationTechnology

SHALABH AGARWALName of the Candidate as inthe 10th Class Certificate

Choice of GATE Paper1. 9.

GATE COPYAPPLICATION NO. 5020208

GATE 2012 APPLICATION FORM

Zone: IIT Kanpur Payment Mode: Payment GatewayPayment Reference No: MBBR1000512765

Fee: Rs. 1000

Date of Birth (DD/MM/YYYY)2. E-mail Address SHALABH43@GMAIL.COM19/11/1990 10.

Gender3. MALE Address for Correspondence 68,MAMIA TOLA11.

MANGAMAL AGENCIES

BARA BAZAR

BAREILLY

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. 243001

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.

504 - Bareilly

818 - Noida

SUNIL KUMAR AGARWAL

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 after

Mobile / Landline No.17. 09219876600

8/3/2019 GATE2012_5020208

3/4

Computer Science and InformationTechnology

SHALABH AGARWALName of the Candidate as inthe 10th Class Certificate

Choice of GATE Paper1. 9.

CANDIDATE COPYAPPLICATION NO. 5020208

GATE 2012 APPLICATION FORM

Zone: IIT Kanpur Payment Mode: Payment GatewayPayment Reference No: MBBR1000512765

Fee: Rs. 1000

Date of Birth (DD/MM/YYYY)2. E-mail Address SHALABH43@GMAIL.COM19/11/1990 10.

Gender3. MALE Address for Correspondence 68,MAMIA TOLA11.

MANGAMAL AGENCIES

BARA BAZAR

BAREILLY

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. 243001

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.

504 - Bareilly

818 - Noida

SUNIL KUMAR AGARWAL

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 after

Mobile / Landline No.17. 09219876600

8/3/2019 GATE2012_5020208

4/4

To

BY SPEED / REGISTERED POST(Please do not Courier)

Chairman, GATE

GATE 2012 Application Form

Indian Institute of Technology Kanpur

FromSHALABH AGARWAL (APPLNO : 5020208)

68,MAMIA TOLA

Kanpur - 208016

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

504CS5020208

MANGAMAL AGENCIES

BARA BAZAR

BAREILLY

243001