ONLINE Application for GATE 2011

Instructions for the Candidate:

1. Your Login ID is DICK1812. Remember your password and do not disclose it to anyone.
2. There are 4 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 - 4 : Address slip to be pasted on the A4 size envelope
7. 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. Attested Copy of SC/ST/PD Certificate (if applicable)
3. Attested Copy of affidavit for change of name (if applicable)

Page - 1
 GATE IIT Madras COPY
APPLICATION FORM FOR GATE 2011
Application No: 7127915 Payment Mode: ICICI Payment Gateway

Zone: IIT Madras Application Fee: Rs. 800/- Payment Reference No: 201010181804002

1. Name of the Candidate as in DICKINS JOHN 11. Address KOCHUPURACKAL (H)

the 10th Class Certificate
ASSAMANNOOR P.O

CHERUKUNNAM

2. Date of Birth (DD/MM/YYYY) 18/12/1988 ERNAKULAM DIST.

PINCODE 683549
3. Gender MALE

4. Nationality INDIAN 14. Year of Degree 2011

15. Discipline Civil/Civil & Environmental/Structural

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

Do You Require a Scribe? No 16. Name of Parent JOHN KURIAKOSE

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

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

18. Phone / Mobile 04842658850

8. Choice of Examination City1 708 - Ernakulam
Number
19. PINCODE of Address 683549
Choice of Examination City2 717 - Kottayam for Correspondence

9. Choice of GATE Paper CE - Civil Engineering

10. E-mail Address dickinsjohnk@yahoo.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
7127915 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: 7127915 Payment Mode: ICICI Payment Gateway

Zone: IIT Madras Application Fee: Rs. 800/- Payment Reference No: 201010181804002

1. Name of the Candidate as in DICKINS JOHN 11. Address KOCHUPURACKAL (H)

the 10th Class Certificate
ASSAMANNOOR P.O

CHERUKUNNAM

2. Date of Birth (DD/MM/YYYY) 18/12/1988 ERNAKULAM DIST.

PINCODE 683549
3. Gender MALE

4. Nationality INDIAN 14. Year of Degree 2011

15. Discipline Civil/Civil & Environmental/Structural

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

Do You Require a Scribe? No 16. Name of Parent JOHN KURIAKOSE

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

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

18. Phone / Mobile 04842658850

8. Choice of Examination City1 708 - Ernakulam
Number
19. PINCODE of Address 683549
Choice of Examination City2 717 - Kottayam for Correspondence

9. Choice of GATE Paper CE - Civil Engineering

10. E-mail Address dickinsjohnk@yahoo.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
7127915 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 CE To

EXAM CITY OF FIRST Chairman, GATE

CHOICE 708
Indian Institute of Technology Madras

Chennai

From
PINCODE 6 0 0 0 3 6
DICKINS JOHN

KOCHUPURACKAL (H)
APPLICATION NO
ASSAMANNOOR P.O

CHERUKUNNAM

ERNAKULAM DIST. 7 1 2 7 9 1 5
PINCODE 6 8 3 5 4 9

Page - 4