INDIAN INSTITUTE OF TECHNOLOGY KANPUR

Application Form For Admissions To Post Graduate 2016-2017

Date:09-APR-2016

Reference No: IITK/2016-17-I/PG/10681

Application Date: 07-APR-2016
Application Status: Applied

1. General Information
Full Name Roshankumar Omprakash Jayswal DOB 17-MAY-1993
Place of Birth Thane Sex Male Marital Status Single
Father's Name Omprakash Kanhaiyalal Jayswal Nationality Indian
Address for Corres. A-102,Yamuna Co-Hsg Society,Lodha
Heaven, Kalyan Shil Road,Near Nilje
Rly Station, Dombivili-East
Dombivili State Maharashtra PinCode 421204
E-Mail roshanjayswal15@gmail.com Phone NA Mobile 8898278795
Category OBC-NCL Person with Disability (PwD) No Religion Hindu

2. Applied Department/Programme Details

Department Electrical Engineering Admission for Degree MS(Research)
Appling directly PhD after BE/BTech from Centrally Funded Technical Institute No
Financial Status Institute Asst. Required Student Status Full Time

Areas of specialization in the Department/Programme

Pref. 1. Microelectronics and VLSI Pref. 2. Photonics
Pref. 3. Signal Processing, Communications and Networks Pref. 4. RF and Microwaves

3. Academic Information/Work Experience

A. GATE,ICMR-JRF,ICAR,DBT-JRF,CEED,CSIR-JRF/LS,UGC-JRF/LS,Other Fellowship Details
Exam Name Exam Discipline Score Rank Exam Year
GATE Electronics and Comm. Engg. 550.0 3661 2016
B. Qualifying Degree already obtained or in Progress
University Name Uni Address 1 Uni Address 2 Rank in University Total Student in Uni
Mumbai University Fort 121, Mahatma Gandhi Road, Kala Ghoda Fort, Mumbai NA NA
Institute Code Institute Name & Place Centrally Funded Technical Inst. (Only applicable Rank in Institute
for direct PhD after BE/BTech)
MH005 Agnel Charities Fr. Conceico Rodrigues Institute of No NA
Technology, Navi Mumbai
Degree Discipline Year of Completed Min. Pass Marks Max. Marks
Gradution
B.E. Electronics And Telecommunication 2015 40.0 100.0
% Marks or Grade Sem. I Sem. II Sem. III Sem. IV Sem. V
Average 79.12 77.25 79.41 85.76 85.05
Sem. VI Sem. VII Sem. VIII Sem. IX Sem. X
83.68 77.5 76.27 0.0 0.0
Overall Marks in % or Grade Average 80.5

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C. Other Degrees Obtained after 10+2(Do not include the degree listed in 4B)
Degree Discipline University Name & Address Institute Name & Address Marks or Completion
CPI Year
D. Working Experiences
Duration Employer Position Nature of work
E. Number of Technical Papers(Provide details separately)
Papers Published in Journals 0 Presented in Conference 1

4. Names and addresses of two referees from whom letters of reference have been obtaioned(For Ph.D Only)
Sr No Referee Name Designation/Position Address Email ID

5. Application Fee Payment Details

Receipt Number : 610019656337
Transaction Amount : 400 Bank Transaction ID : 318919
Transaction Date : 09-04-2016 00:00:00 Transaction Status : OK
Transaction Response : Approved Payment Gateway : AXIS
Payment Mode : Credit/Debit Card Card Type : VISA

Declaration by the Applicant

Certified that all information provided by me in this form is correct to the best of my knowledge and belief. I understand that any wilful misrepresentation of facts
will result in my dismissal from the institute. If admitted, I shall abide by all the rules and regulations of the institute.

Date: 07-APR-2016 Signature:

Checklist of Uploaded Documents

1. Applicant Photograph
2. Applicant Signature
3. Caste Certificate
4. Date of Birth (DOB) Certificate or High School (Class 10) Certificate with DOB
5. GATE Score Card
6. Marks/Grade sheet upto last/current semester (Consolidated)
7. Paper Published 1
8. Qualifying Degree Certificate

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