13/04/2017 ApplicationForm

IndianInstituteofTechnologyGuwahati
ApplicationFormforAdmissiontoMAProgramme

1.ApplicationNumber: 110

2.ApplicantName: AdityaNarayanRai

3.Gender: MALE

4.Father/GuardianName: ChandramauliRai

5.DateofBirth: 19970801
6.MaritalStatus: SINGLE Applicant'sPhoto
7.Nationality: Indian
8.CasteCategory: General
9.PhysicallyDisable: NO
10.StudentCategory: REGULAR(FULLTIME)
11.AnyQualifyingdegreefromIIT's NO

12.CorrespondenceAddress:
13.PermanentAddress:
VillageKatgharaMahaluPOUnduraMadubanDistrictMauUttarPradeshPin221603
Vill./Town/City:Mau
State:UttarPradesh
Pincode:221603
STDcode:
TelephoneNumber:
FaxNumber:
Email:adityanarayan1709@gmail.com
MobileNumber:8419891511
VillageKatgharaMahaluPOUnduraMadubanDistrictMauUttarPradeshPin221603
Vill./Town/City:Mau
State:UttarPradesh
Pincode:221603
STDcode:
TelephoneNumber:
FaxNumber:
Email:adityanarayan1709@gmail.com
MobileNumber:8419891511

14.Applicant'sChoices:
Departmentapplied AreaOfInterests
1.HumanitiesandSocialSciences 1.HumanitiesandSocialSciences

15.AcademicRecord:

SlNo. ExamName Board/University %/CGPA/CPI Grade SubjectsTaken Yearof Status

Format Passing
Class10thOR CGPAout ENGLISHHINDI
1. CBSE 9.6 MATHSSOCIAL 2012 Passed
Equi. of10
SCIENCESCIENCE
ENGLISHHINDI
Class12thOR %outof
2. Equi. CBSE 68.4 100 MATHSPHYSICS 2014 Passed
CHEMISTRY
B.A.HONS. BANARASHINDU CGPAout SOCIOLOGY
3. 8.16 POLITICALSCIENCE 2017 Appeared
SOCIOLOGY UNIVERSITY of10
ECONOMICS

16.ProfessionalExperience:
SlNo. NameOfOrganization PositionHeld TypeOfwork StartDate EndDate

17.DemandDraft:
DemandDraft[(Rs.150/forGen/OBCcandidates)and(Rs.75/forSC/ST/PDcandidates)]willberequiredatthetimeofWrittenTestand/or
https://auto.iitg.ernet.in/ma/print_application_details.jsp?rollno=110 1/2
13/04/2017 ApplicationForm
DemandDraft[(Rs.150/forGen/OBCcandidates)and(Rs.75/forSC/ST/PDcandidates)]willberequiredatthetimeofWrittenTestand/or
Interview,ifcalledfor.Pleaseseedetailsaboutitin'ApplicationProcedure'.


18.ListofEnclosures:
UploadedLastQualifyingExaminationMarksheet.
AttestedcopiesofallsupportingdocumentswillberequiredatthetimeofWrittenTestand/orInterview,ifcalledfor.Pleaseseedetailsaboutit
in'ApplicationProcedure'.

Declaration

Iherebydeclarethattheentriesmadeinthisapplicationformarecorrecttothebestofmyknowledgeandbelief.Ifselectedforadmission,I
promisetoabidebytherulesandregulationsoftheInstitute.

InotethatthedecisionoftheInstituteisfinalinregardtoselectionforadmissionandassignmenttoaparticularDepartment/Centreand
fieldofstudy.TheInstituteshallhavetherighttotakeanyactionitdeemsfit,includingexpulsion,againstmeatanytimeaftermyadmission,ifit
isfoundthatanyinformationfurnishedbymeisincorrect.

Place:
Date: Signature

2017IITGOfficeAutomation|IITGuwahati

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