ONLINE Application for GATE 2011

Instructions for the Candidate:

1.

Your Login ID is DHIM0710. Remember your password and do not disclose it to anyone.

2.

There are 5 Pages in this file. These pages should be printed on A4 sheets.

3.

Page - 1: Instructions for the candidate to be retained by you carefully

4.

Page - 2 : Application Form (GATE Copy)

a. Paste your recent color photo (3cm x 4cm) in designated place
b. Sign at designated places

5.

Page - 3 : Application Form (CANDIDATE Copy) to be retained by you for your reference

6.

Page - 5 : Bank challan in triplicate. Take it to any SBI branch and pay the fee. The Bank will retain a
copy with them and will return two copies to you. In those two copies, retain the Candidate's copy with
you and attach Institute's copy with Application Form

7.

Page - 4 : Address slip to be pasted on the A4 size envelope

8.

Insert completed Application Form (GATE Copy) and attested copies of all applicable documents
(SC/ST/PD Certificate, Affidavit for change of name) into A4 size envelope, without folding and send by
Speed Post (preferably) or by Registered Post to Chairman, GATE, IIT Kharagpur

List of Documents to be sent to GATE IIT Kharagpur:

1.

Application Form (GATE Copy)

2.

Bank Challan (Institute's Copy)

3.

Attested Copy of SC/ST/PD Certificate (if applicable)

4.

Attested Copy of affidavit for change of name (if applicable)

Page - 1

GATE IIT Kharagpur COPY

APPLICATION FORM FOR GATE 2011
Application No:
Zone:

6126167

Payment Mode:

IIT Kharagpur

1. Name of the Candidate as in

the 10th Class Certificate

Bank Challan (State Bank of India)

Application Fee:
DHIMAN DAS

Rs. 800/P-202, BASUNAGAR

11. Address

MADHYAMGRAM, KOL-700129

2. Date of Birth (DD/MM/YYYY)

07/10/1989

3. Gender

MALE

4. Nationality

INDIAN

5. Category

General

6. Person with Disability (PD)

No

Do You Require a Scribe?

PINCODE

700129

14. Year of Degree

2012

15. Discipline

Instrumentation/ Electronics/Control

No

16. Name of Parent

SANKAR DAS

7. Qualifying Degree

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

17. State/Union Territory of

Permanent Residence

West Bengal

8. Choice of Examination City1

611 - Kolkata

09051119767

Choice of Examination City2

411 - Kalyani

18. Phone / Mobile

Number
19. PINCODE of Address
for Correspondence

9. Choice of GATE Paper

IN - Intrumentation Engineering

10. E-mail Address

dhiman.das19@gmail.com

700129

I hereby declare that all the particulars stated in this application form are true to the best of my knowledge and belief. 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 2011.
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 2011 score is liable to be cancelled.

Place:
Date:
Full Signature of the Candidate
(do not sign in capital letters)

12. Photograph

6126167

13.

Full Signature of the Candidate

using black ball point pen only
(do not sign in capital letters)

Paste a front
facial high
contrast recent
color photograph
3cm x 4cm
without any
signature or
attestation

Send this form along with the necessary documents to IIT Kharagpur

Page - 2

CANDIDATE COPY
APPLICATION FORM FOR GATE 2011
Application No:
Zone:

6126167

Payment Mode:

IIT Kharagpur

1. Name of the Candidate as in

the 10th Class Certificate

Bank Challan (State Bank of India)

Application Fee:
DHIMAN DAS

Rs. 800/P-202, BASUNAGAR

11. Address

MADHYAMGRAM, KOL-700129

2. Date of Birth (DD/MM/YYYY)

07/10/1989

3. Gender

MALE

4. Nationality

INDIAN

5. Category

General

6. Person with Disability (PD)

No

Do You Require a Scribe?

PINCODE

700129

14. Year of Degree

2012

15. Discipline

Instrumentation/ Electronics/Control

No

16. Name of Parent

SANKAR DAS

7. Qualifying Degree

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

17. State/Union Territory of

Permanent Residence

West Bengal

8. Choice of Examination City1

611 - Kolkata

09051119767

Choice of Examination City2

411 - Kalyani

18. Phone / Mobile

Number
19. PINCODE of Address
for Correspondence

9. Choice of GATE Paper

IN - Intrumentation Engineering

10. E-mail Address

dhiman.das19@gmail.com

700129

I hereby declare that all the particulars stated in this application form are true to the best of my knowledge and belief. 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 2011.
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 2011 score is liable to be cancelled.

Place:
Date:
Full Signature of the Candidate
(do not sign in capital letters)

12. Photograph

6126167

13.

Full Signature of the Candidate

using black ball point pen only
(do not sign in capital letters)

Paste a front
facial high
contrast recent
color photograph
3cm x 4cm
without any
signature or
attestation

Retain this page for your reference

Page - 3

BY SPEED POST / REGISTERED POST

GATE 2011
GATE PAPER CODE

IN

To

EXAM CITY OF FIRST

CHOICE

611

Chairman, GATE
Indian Institute of Technology Kharagpur
Kharagpur

From

PINCODE 7

DHIMAN DAS
P-202, BASUNAGAR

APPLICATION NO

MADHYAMGRAM, KOL-700129

6 1 2 6 1
PINCODE

6 7

Page - 4

CASH VOUCHER

BANK'S COPY CASH VOUCHER

BRANCH (CODE NO.

GATE 2011 Online Application Fee Payment

GATE 2011 FEE COLLECTION A/C NO. 31372883605

Name of the Candidate
Present Address

BRANCH (CODE NO.

P-202, BASUNAGAR MADHYAMGRAM, KOL-

P-202, BASUNAGAR MADHYAMGRAM, KOL-

- 700129

700129

BRANCH (CODE NO.

DHIMAN DAS

Present Address

P-202, BASUNAGAR MADHYAMGRAM, KOL-

- 700129

700129

- 700129

Date of Birth

07/10/1989

Date of Birth

07/10/1989

Date of Birth

07/10/1989

Mobile / Landline No:

09051119767

Mobile / Landline No:

09051119767

Mobile / Landline No:

09051119767

E-mail Address:

dhiman.das19@gmail.com

E-mail Address:

dhiman.das19@gmail.com

E-mail Address:

dhiman.das19@gmail.com

Category :

General

Category :

General

Category :

General

Physically Disabled :

No

Physically Disabled :

No

Physically Disabled :

No

Head

Credit to

Amount

Application Fees
Bank's Charges
Total

Head

Amount

Credit to

31372883605

Application Fees

Rs.800.00

31372883605

Application Fees

Rs. 800.00

31372883605

Rs. 30.00

98353XXXXXX

Bank's Charges

Rs. 30.00

98353XXXXXX

Bank's Charges

Rs. 30.00

98353XXXXXX

Rupees eight hundred and thirty only.

Total

Rs. 830.00

Amount in words :

Rupees eight hundred and thirty only.

JOURNAL NUMBER

Total

Rs. 830.00

Amount in words :

Rupees eight hundred and thirty only.

Signature of the Candidate/Remitter

Signature of the Candidate/Remitter

Signature of the Candidate/Remitter

For Receiving Branch use only

For Receiving Branch use only

APPLICATION NUMBER

Credit to

Amount

Rs. 800.00

Rs. 830.00

Amount in words :

Head

APPLICATION NUMBER

6126167

JOURNAL NUMBER

For Receiving Branch use only

APPLICATION NUMBER

6126167

JOURNAL NUMBER

6126167

1. Please credit Rs.30/- to your Branch Commission

A/c No.98353XXXXXX
2. Please note to write the Journal Number in all the challans.
3. Please feed the Application No. in REG/ID/Ref No. Column
and Name of the Candidate in the menu while posting.

1. Please credit Rs.30/- to your Branch Commission

A/c No.98353XXXXXX
2. Please note to write the Journal Number in all the challans.
3. Please feed the Application No. in REG/ID/Ref No. Column
and Name of the Candidate in the menu while posting.

1. Please credit Rs.30/- to your Branch Commission

A/c No.98353XXXXXX
2. Please note to write the Journal Number in all the challans.
3. Please feed the Application No. in REG/ID/Ref No. Column
and Name of the Candidate in the menu while posting.

SEAL / DATE

SEAL / DATE

SEAL / DATE

AUTHORISED SIGNATORY

AUTHORISED SIGNATORY

GATE 2011 Online Application Fee Payment

GATE 2011 FEE COLLECTION A/C NO. 31372883605
Name of the

DHIMAN DAS

Present Address

CANDIDATE'S COPY

GATE 2011 Online Application Fee Payment

GATE 2011 FEE COLLECTION A/C NO. 31372883605
Name of the

DHIMAN DAS

700129

INSTITUTES COPY CASH VOUCHER

AUTHORISED SIGNATORY