INDIAN INSTITUTE OF TECHNOLOGY KANPUR

APPLICATION F ORM$ F OR ADMISSION TO P OST-G RADUATE P ROGRAMME

(For filling this application for m see instr uctions over leaf)
Paste your
photograph
here
1. Full Name :

2. Date of Birth : . Place of Birth : . Sex: Male/Female

5. Marital Status: 6. Nationality :

7. Father ’s Name :
Codes for Items 11-16 ar e given over leaf
8. Address of Cor respondence :
11. Depar tment/Pr ogramme

12. Admission for Degr ee

13. Categor y
State: Pin Code :
14. Student Status
9. If available, please pr ovide:
15. Financial Status
Phone No. : Mobile No. :
16. Physically Handicapped
E-mail address :

10. Details of Demand Dr aft

a) Amount Rs . ……………………………………..… No. …………………..……….. Date ………………………….………

b) Issued by (Bank Name & Br anch) …………….…………………….…………….……….……………………………………..

17. Academic Recor d/Wor k Experience

A. GATE, CSIR, UGC, other fellowship exam details (*)

Exam Name Exam discipline GATE Scor e/CSIR/UGC Rank Exam Year

B. Qualifying Degr ee (*) alr eady obtained or in pr ogress

Institute/ College Univer sity Discipline Degree Exam Date Final Pass
(Name & Address) (Name & Address) results Mar ks %
expected or Gr ade
by Aver age

% Mar ks or Sem. I Sem. II Sem. III Sem. IV Over all % or

Gr ade Aver age Gr ade Aver age
(if degree completed)
Sem. V Sem. VI Sem. VII Sem. VIII

C. Other Degrees (*) obtained after 10+2 (Do not include the degr ee listed in 17 B)

Institute/ College Univer sity Discipline Degr ee Mar ks or Date of

(Name & Address) (Name & Address) CPI completion
 D. Wor king Experience (**)

Dates (fr om-to) Employer Position Nature of Wor k

E. Number of Technical Paper s: Published in J our nals Presented in Confer ences

Provide details separately

(*) Attach attested copies of certificates, mar k sheet etc. See checklist over leaf for cer tificates r equir ed.
(**) A candidate presently wor king must provide a “No Objection/Relieving certificate” from the employer.
($) Photocopies of this form or copies downloaded from the IIT Kanpur website http://www.iitk.ac.in/d oaa/admissions.html) are acceptable.

18. Areas of specialization in the Department/Programme (See Infor mation Brochure)

Pref. 1 Pref. 2

Pref. 3 Pref. 4

19. Names and addresses of two r efer ees fr om whom letters of r eference have been obtained (For Ph.D. applicants only)

1. 2.

20. Declar ation by the applicant:

Certified, that all information provided by me on 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 : Signature :
 I NSTR UC T I O NS FOR F IL L ING TH IS FORM

1. Either TYPE or PRINT the entr ies on the for m neatly.

2. Go through the codes for Items 11-16 given below, a nd fill them car efully in the boxes on Page 1.
3. All items mar ked with an asterisk (*) require you to submit an attested copy of some document. PLEASE DO NOT SEND
ORIGINALS. Documents for which attested copies are required are given in the checklist. Please tick off the items in this
checklist you are attaching to this for m.
4. The application fee of Rs. 200/- for candidates in General/OBC/PD and Rs. 100/- for SC/ST must be paid through demand dr aft
payable to The Registrar I I T Kanpur at Kanpur

C ODES (FOR I TEMS 11-16)

Item 11: Department/Pr ogramme Codes: {A erospace Engg. = AE}, {Chemical Engg. = CHE}, {Civil Engg. = CE}, {Computer Science
& Engg. = CSE}, {Electrical Engg. = EE}, (Design Programme = DP), {Industr ial & Management Engg. = IME} {Mechanical
Engg. = ME}, {Materials Science & Engg. = MSE} {Chemistr y = CHM}, {Mathematics and Statistics = MTS}, {Physics =
PHY}, {Statistics = STA}, {Humanities & Social Sciences = H SS}, {Laser Technology = LT}, {Mater ials Science Programme =
MSP}, {Nuclear Engg. & Technology = N ET}, {Environmental Engg. & Management = EEM}, {Biological Sciences and Bio-
Engineering = BSBE}.

Item 12: MT = M.Tech., PH = Ph.D. , MD = M. Des.

Item 13: Categor y

SC*=Scheduled Caste (certificate required); ST*=Scheduled Tr ibe (cer tificate required); OBC*=Other Backward Class
(Certificate of Non-cr eamy layer r equired); GN=Gener al; FN=Foreign Nationals;

Item 14: Student Status- Full Time = FT; Par t-Time = PT, Exter nal = EXT

Item 15: Financial Status: Sponsored (*)= SD; Institute Assistantship requested= IA; Other = OTH

Item 16: Physically Handicapped= PH

C HECK LIST (C IRCLE TH E E NCLOSED DOCUMENTS). SEND ONLY ATTESTED COPIES (NOT O RIGINALS).

1. Date of Birth (DOB) Cer tificate or High School (Class Te n) Certificate with DOB (Required for all candidates)

2. SC/ST/OBC Certificate if applicable (Item 13)

3. Cer tificate of Physical Status (Type of disab ility to be attached).

4. Sponsor ship certificate for sponsored candidates. (Item 15)

5. GATE/CSIR/UGC score car d (Item 17 A)

6. Copies of mar k/gr ade sheets (Items 17 B & 17C)

7. No Objection/relieving Certificate fr om employer (for employed candidates)

8. The Demand dr aft for the application fee of Rs. 200/- or Rs. 100/- as applicable

9. Two letters of r eference (for Ph.D. applicants only)

10. One self addressed envelope of 23cm x10cm.

The completed Application For m must reach on or before

Apr il 15 for admission in July Semester

Mailing Address for Submission of Applications:

The Convenor, DPGC +

Department/Programme of (kindly mentioned the Department name where you are seeking your admission)
Indian Institute of Technology Kanpur
Kanpur - 208 016 U.P.

+
Department Post-Graduate Committee.