ONLINE Application for GATE 2011

Instructions for the Candidate:

1. Your Login ID is BHAV17052. 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, IISc Bangalore

List of Documents to be sent to GATE IISc Bangalore:

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 IISc Bangalore COPY
APPLICATION FORM FOR GATE 2011
Application No: 1109495 Payment Mode: Bank Challan (Indian Bank)

Zone: IISc Bangalore Application Fee: Rs. 400/-

1. Name of the Candidate as in BHAVESH KUMAR JAIN 11. Address #398/1

the 10th Class Certificate
SHIVAYYA MUTTA ROAD

DEVRAJA MOHALLA

2. Date of Birth (DD/MM/YYYY) 17/05/1987 MYSORE

PINCODE 570024
3. Gender MALE

4. Nationality INDIAN 14. Year of Degree 2010

15. Discipline Biochemistry

5. Category General

6. Person with Disability (PD) Yes

Do You Require a Scribe? No 16. Name of Parent SUMERMAL JAIN S

7. Qualifying Degree M.Sc./M.C.A./M.A. 17. State/Union Territory of Karnataka

Permanent Residence

18. Phone / Mobile 09916027493

8. Choice of Examination City1 111 - Mysore
Number
19. PINCODE of Address 570024
Choice of Examination City2 103 - Bangalore for Correspondence

9. Choice of GATE Paper XL - Life Sciences

10. E-mail Address jaincool123@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
1109495 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 IISc Bangalore

Page - 2
 CANDIDATE COPY
APPLICATION FORM FOR GATE 2011
Application No: 1109495 Payment Mode: Bank Challan (Indian Bank)

Zone: IISc Bangalore Application Fee: Rs. 400/-

1. Name of the Candidate as in BHAVESH KUMAR JAIN 11. Address #398/1

the 10th Class Certificate
SHIVAYYA MUTTA ROAD

DEVRAJA MOHALLA

2. Date of Birth (DD/MM/YYYY) 17/05/1987 MYSORE

PINCODE 570024
3. Gender MALE

4. Nationality INDIAN 14. Year of Degree 2010

15. Discipline Biochemistry

5. Category General

6. Person with Disability (PD) Yes

Do You Require a Scribe? No 16. Name of Parent SUMERMAL JAIN S

7. Qualifying Degree M.Sc./M.C.A./M.A. 17. State/Union Territory of Karnataka

Permanent Residence

18. Phone / Mobile 09916027493

8. Choice of Examination City1 111 - Mysore
Number
19. PINCODE of Address 570024
Choice of Examination City2 103 - Bangalore for Correspondence

9. Choice of GATE Paper XL - Life Sciences

10. E-mail Address jaincool123@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
1109495 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 XL To

EXAM CITY OF FIRST Chairman, GATE

CHOICE 111
Indian Institute of Science Bangalore

Bangalore

From
PINCODE 5 6 0 0 1 2
BHAVESH KUMAR JAIN

#398/1
APPLICATION NO
SHIVAYYA MUTTA ROAD

DEVRAJA MOHALLA

MYSORE 1 1 0 9 4 9 5
PINCODE 5 7 0 0 2 4

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 BHAVESH KUMAR JAIN Name of the Candidate BHAVESH KUMAR JAIN Name of the Candidate BHAVESH KUMAR JAIN

Present Address #398/1 SHIVAYYA MUTTA ROAD DEVRAJA Present Address #398/1 SHIVAYYA MUTTA ROAD DEVRAJA Present Address
#398/1 SHIVAYYA MUTTA ROAD DEVRAJA
in CAPITAL LETTERS MOHALLA MYSORE - 570024 in CAPITAL LETTERS MOHALLA MYSORE - 570024 in CAPITAL LETTERS MOHALLA MYSORE - 570024
with Pin Code with Pin Code with Pin Code

Date of Birth 17/05/1987 Date of Birth 17/05/1987 Date of Birth 17/05/1987

Mobile / Landline No: 09916027493 Mobile / Landline No: 09916027493 Mobile / Landline No: 09916027493

E-mail Address jaincool123@gmail.com E-mail Address jaincool123@gmail.com E-mail Address jaincool123@gmail.com

Category : General Category : General Category : General
Physically Disabled : Yes Physically Disabled : Yes Physically Disabled : Yes
Amount : Rs.430/- Amount : Rs.430/- Amount : Rs.430/-

Amount in words : Rupees four hundred and thirty only. Amount in words : Rupees four hundred and thirty only. Amount in words : Rupees four 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 1109495 Signature Application 1109495 Signature Application 1109495 Signature

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

Branch Date Branch Date Branch Date

Name Name Name