ONLINE Application for GATE 2011

Instructions for the Candidate:

1. Your Login ID is NAND01064. 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 Indian Bank 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 Madras

List of Documents to be sent to GATE IIT Madras:

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 Madras COPY
APPLICATION FORM FOR GATE 2011
Application No: 7176178 Payment Mode: Bank Challan (Indian Bank)

Zone: IIT Madras Application Fee: Rs. 800/-

1. Name of the Candidate as in NANDHA KUMAR R M 11. Address 2/3-34,

the 10th Class Certificate
ANNAM AGRO SERVICE,

METTUR MAIN ROAD,

2. Date of Birth (DD/MM/YYYY) 01/06/1991 KOLATHUR.

PINCODE 636303
3. Gender MALE

4. Nationality INDIAN 14. Year of Degree 2012

15. Discipline Electronics & Comm./Electronics

5. Category General Engg./Comm.
Engg./Telecommunication Engg.
6. Person with Disability (PD) No

Do You Require a Scribe? No 16. Name of Parent MATHESAN R

7. Qualifying Degree B.E./B.Tech./ B.Sc. 17. State/Union Territory of Tamil Nadu

(Engg.)/B.Sc.(Tech.)/B.Arch. Permanent Residence

18. Phone / Mobile 09894940102

8. Choice of Examination City1 706 - Coimbatore
Number
19. PINCODE of Address 636303
Choice of Examination City2 727 - Salem for Correspondence

9. Choice of GATE Paper EC - Electronics and Communication

Engineering
10. E-mail Address nandharm@gmail.com

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

Paste a front
facial high
contrast recent
13. Full Signature of the Candidate color photograph
7176178 using black ball point pen only 3cm x 4cm
(do not sign in capital letters) without any
signature or
attestation

Send this form along with the necessary documents to IIT Madras

Page - 2
 CANDIDATE COPY
APPLICATION FORM FOR GATE 2011
Application No: 7176178 Payment Mode: Bank Challan (Indian Bank)

Zone: IIT Madras Application Fee: Rs. 800/-

1. Name of the Candidate as in NANDHA KUMAR R M 11. Address 2/3-34,

the 10th Class Certificate
ANNAM AGRO SERVICE,

METTUR MAIN ROAD,

2. Date of Birth (DD/MM/YYYY) 01/06/1991 KOLATHUR.

PINCODE 636303
3. Gender MALE

4. Nationality INDIAN 14. Year of Degree 2012

15. Discipline Electronics & Comm./Electronics

5. Category General Engg./Comm.
Engg./Telecommunication Engg.
6. Person with Disability (PD) No

Do You Require a Scribe? No 16. Name of Parent MATHESAN R

7. Qualifying Degree B.E./B.Tech./ B.Sc. 17. State/Union Territory of Tamil Nadu

(Engg.)/B.Sc.(Tech.)/B.Arch. Permanent Residence

18. Phone / Mobile 09894940102

8. Choice of Examination City1 706 - Coimbatore
Number
19. PINCODE of Address 636303
Choice of Examination City2 727 - Salem for Correspondence

9. Choice of GATE Paper EC - Electronics and Communication

Engineering
10. E-mail Address nandharm@gmail.com

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

Paste a front
facial high
contrast recent
13. Full Signature of the Candidate color photograph
7176178 using black ball point pen only 3cm x 4cm
(do not sign in capital letters) without any
signature or
attestation

Retain this page for your reference

Page - 3
 BY SPEED POST / REGISTERED POST

GATE 2011
GATE PAPER CODE EC To

EXAM CITY OF FIRST Chairman, GATE

CHOICE 706
Indian Institute of Technology Madras

Chennai

From
PINCODE 6 0 0 0 3 6
NANDHA KUMAR R M

2/3-34,
APPLICATION NO
ANNAM AGRO SERVICE,

METTUR MAIN ROAD,

KOLATHUR. 7 1 7 6 1 7 8
PINCODE 6 3 6 3 0 3

Page - 4
 CANDIDATE’S COPY
PAY IN SLIP BANK'S COPY PAY IN SLIP INSTITUTE’S COPY PAY IN SLIP

PAYABLE AT ALL BRANCHES OF PAYABLE AT ALL BRANCHES OF PAYABLE AT ALL BRANCHES OF

INDIAN BANK INDIAN BANK INDIAN BANK
Paid in to the credit of IIT MADRAS GATE 2011 Paid in to the credit of IIT MADRAS GATE 2011 Paid in to the credit of IIT MADRAS GATE 2011
A/C no 899746136 , ADYAR BRANCH CHENNAI, A/C no 899746136 , ADYAR BRANCH CHENNAI, A/C no 899746136 , ADYAR BRANCH CHENNAI,
BRANCH CODE : 79 BRANCH CODE : 79 BRANCH CODE : 79
Name of the Candidate NANDHA KUMAR R M Name of the Candidate NANDHA KUMAR R M Name of the Candidate NANDHA KUMAR R M

Present Address 2/3-34, ANNAM AGRO SERVICE, METTUR Present Address 2/3-34, ANNAM AGRO SERVICE, METTUR Present Address 2/3-34, ANNAM AGRO SERVICE, METTUR
in CAPITAL LETTERS MAIN ROAD, KOLATHUR. - 636303 in CAPITAL LETTERS MAIN ROAD, KOLATHUR. - 636303 in CAPITAL LETTERS MAIN ROAD, KOLATHUR. - 636303
with Pin Code with Pin Code with Pin Code

Date of Birth 01/06/1991 Date of Birth 01/06/1991 Date of Birth 01/06/1991

Mobile / Landline No: 09894940102 Mobile / Landline No: 09894940102 Mobile / Landline No: 09894940102

E-mail Address nandharm@gmail.com E-mail Address nandharm@gmail.com E-mail Address nandharm@gmail.com

Category : General Category : General Category : General
Physically Disabled : No Physically Disabled : No Physically Disabled : No
Amount : Rs.830/- Amount : Rs.830/- Amount : Rs.830/-

Amount in words : Rupees eight hundred and thirty only. Amount in words : Rupees eight hundred and thirty only. Amount in words : Rupees eight hundred and thirty only.
(*Inclusive of Bank Charge) (*Inclusive of Bank Charge) (*Inclusive of Bank Charge)
Name of the Name of the Name of the
Receiving Branch Receiving Branch Receiving Branch

Signature of the candidate Signature of the candidate Signature of the candidate

FOR BANK’S USE FOR BANK’S USE FOR BANK’S USE

Journal No: Branch Journal No: Branch Journal No: Branch

Code Code Code

Application 7176178 Signature Application 7176178 Signature Application 7176178 Signature

Number : of Number : of Number : of
cashier cashier cashier

Branch Date Branch Date Branch Date

Name Name Name