Application Form

https://auto.iitg.ernet.in/phd/print_application_details.jsp?rollno=6924

Indian Institute of Technology Guwahati

Application Form for Admission to PhD Programme

1. Application Numbe r : 2. Applicant Name : 3. Ge nde r : 4. Father/Spouse /Guardian Name : 5. Date of Birth : 6. Marital Status : 7. Nationality : 8. Caste Category : 9. Student Category :

6924 MUKAT male ASHA DEVI BIHARI

1988-08-09 single Indian OBC(Non Creamy Laye r) Re gular Physically Disable : NO Applicants Photo

10. Correspondence Addre ss :

Are a :Vill./Town/City :State :Pincode :STD code :Telephone Numbe r :Fax Numbe r :Email :Mobile Numbe r :-

VILL-BHAGORI, POST-KANAWAR, TEH-BAYANA, DIST-BHARATPUR,(RAJ) BAYANA RAJASTHAN 321401 05648 681458 abhilash.dhake d@yahoo.in 7503199088

11. Pe rmane nt Addre ss :

Are a :Vill./Town/City :State :Pincode :STD code :Telephone Numbe r :Fax Numbe r :Email :Mobile Numbe r :-

VILL-BHAGORI, POST-KANAWAR, TEH-BAYANA, DIST-BHARATPUR,(RAJ) BAYANA RAJASTHAN 321401 05648 681458 abhilash.dhake d@yahoo.in 7503199088

12. Applicant's Choices :

Departme nts/Ce ntre s applie d 1. Biote chnology

Are a Of Inte re sts 1. PLANT BIOTECHNOLOGY 2. GENETIC ENGINEERING 3. BIOCHEMISTRY

13. Academic Re cord : Sl No. 1. Exam Name Class 10th OR Equi. Bord/Unive rsity BOARD OF SEC.EDUCATION, RAJASTHAN %Marks/CGPA/CPI Subje ct Take n 66.17 HINDI,ENG,SCIENCE,SOCIAL SCIENCE,MATHS,THIRD LANGUAGE Ye ar 2003

1 of 2

4/21/2012 10:32 PM

Application Form

https://auto.iitg.ernet.in/phd/print_application_details.jsp?rollno=6924

2. 3. 4.

CLASS 12th B.Sc M.Sc

BOARD OF SEC.EDUCATION, RAJASTHAN UNIVERSITY OF RAJASTHAN SHARDA UNIVERSITY

74.62 74.71 9.12

HINDI,ENG,PHYSICS,CHEMISTRY,BIOLOGY BIOTECHNOLOGY BIOTECHNOLOGY

2006 2010 2012

14. Profe ssional Expe rie nce : Sl No. Name Of Organisation Position He ld Type Of work Start Date End Date

15. List Of Publication : Sl No. Title of Pape r Name Of Author(s) Journal Name Volume Year

16. Demand Draft : Demand Draft [ (Rs.150/- for Gen/OBC candidate s) and (Rs.75/- for SC/ST/PD candidate s) ] will be re quired at the time of Written Te st and/or Inte rview, if called for. Ple ase se e de tails about it in 'Application Procedure '. 17. Qualifying Exam : GATE :: Discipline : BT Marks:37 Score:331 Rank:1795 18. List of Enclosure s : Atte ste d copies of all supporting docume nts will be re quire d at the time of Writte n Te st and/or Intervie w, if calle d for.Ple ase se e de tails about it in 'Application Proce dure '. Valid Up To:2014-03-14

De claration I hereby declare that the e ntrie s made in this application form are corre ct to the be st of my knowle dge and be lie f. If selecte d for admission, I promise to abide by the rule s and regulations of the Institute .

I note that the de cision of the Institute is final in re gard to selection for admission and assignme nt to a particular de partme nt and fie ld of study. The Institute shall have the right to take any action it de e ms fit, including expulsion, against me at any time afte r my admission, if it is found that any information furnishe d by me is incorrect. Place : Date : Signature

2 of 2

4/21/2012 10:32 PM