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Appli Form 2007

This document is an application form for admission to a post-graduate program. It requests basic personal information such as name, date of birth, address, academic history, work experience, references, and a declaration signed by the applicant. Instructions are provided on filling out the form correctly, including codes for different fields and a checklist of required documents to submit along with the application.

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69 views

Appli Form 2007

This document is an application form for admission to a post-graduate program. It requests basic personal information such as name, date of birth, address, academic history, work experience, references, and a declaration signed by the applicant. Instructions are provided on filling out the form correctly, including codes for different fields and a checklist of required documents to submit along with the application.

Uploaded by

api-3748735
Copyright
© Attribution Non-Commercial (BY-NC)
Available Formats
Download as PDF, TXT or read online on Scribd
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application form $ for admission to post-graduate programme

(for filling this application form see instructions overleaf)

paste your
photograph
here
1. full name : wagle ganesh jayvant
2. date of birth : 17 mar 1984 3. place of birth: dombivli 4. sex: male
5. marital status: single 6. nationality: indian
7. father's name : wagle jayvant yashwant
8. address for corespondence: codes for items 11-16 are given overleaf

11. department/programme

12. admission for degree


state: maharashtra pin code : 421202
9. if available, please provide : 13. category

phone no. : 0251 1234567 fax no. : ________________ 14. student status
e-mail address : [email protected]
15. financial status
10. details of demand draft
16. physically handicapped
a) amount rs. …………… no. …………….. dt. ………………

b) bank & branch issued …………….…………………….…………….……….……………………………………..

17. academic record/work experience


a. gate, csir, ugc, other fellowship exam details (*)
exam name exam discipline percentile score exam year

b. qualifying degree (*) already obtained or in progress


institute/ college university discipline degree exam date final results min. pass marks %
(name & address) (name & address) expected by or grade average

% marks or sem. i sem. ii sem. iii sem. iv


grade average overall % or
grade average
sem. v sem. vi sem. vii sem. viii (if degree completed)

c. other degrees (*) obtained after 10+2 (do not include the degree listed in 17 b)
institute/ college university discipline degree marks or cpi date of completion
(name & address) (name & address)

d. working experience (**)


dates (from-to) employer position nature of work

e. number of technical papers: published in journals presented in conferences


provide details separately

(*) attach attested copies of certificates, marksheet etc. see checklist overleaf for certificates required.
(**) a candidate presently working (including those on projects) 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/doaa/admissions.html) are acceptable.
pref. 1 pref. 2
pref. 3 pref. 4

19. names and addresses of two referees from whom letters of reference have been obtained (for ph.d. applicants only)
1. 2.

20. declaration by the applicant:

certified that all information provided by me in 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 : 5 april 2007 signature :

instructions for filling this form


1. either type or print the entries on the form neatly.
2. go through the codes for items 11-16 given below, and fill them carefully in the boxes on page 1.
3. all items marked 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 form.
4. the application fee of rs. 200/- for candidates in general/obc/ph and rs. 100/- for sc/st must be paid through demand draft
payable to the registrar i i t kanpur at kanpur

codes (for items 11-16)


item 11: department/programme codes: {aerospace engg. = ae}, {chemical engg. = che}, {civil engg. = ce}, {computer science & engg. = cse},
{electrical engg. = ee}, (design programme = dp), {industrial & management engg. = ime} {mechanical engg. = me}, {materials &
metallurgical engg. = mme} {chemistry = chm}, {mathematics and statistics = mts}, {physics = phy} , {statistics = sta} , {humanities &
social sciences = hss}, {laser technology = lt}, {materials science programme = msp}, {nuclear engg. & technology = net},
{environmental engg. & management = eem}, {biological sciences and bio-engineering = bsbe}.
item 12: mt = m.tech., ph = ph.d. , md = m. des.
item 13: category
sc*: scheduled caste (certificate required); st*: scheduled tribe (certificate required); gn: general; fn: foreign nationals;
obc*: other backward classes (certificate required)
item 14: student status : full time : ft; part-time : pt
item 15: financial status: sponsored (*): sd; institute assistantship requested: ia
item 16: physically handicapped: ph

checklist (circle the enclosed documents). send only attested copies (not originals).

1. date of birth (dob) certificate or high school (class ten) certificate with dob (required for all candidates)
2. sc/st/obc certificate if applicable (item 13)
3. certificate of physical status (type of disability to be attached).
4. sponsorship certificate for sponsored candidates. (item 15)
5. gate/csir/ugc score card (item 17 a)
6. copies of mark/grade sheets (items 17 b & 17c)
7. no objection/relieving certificate from employer (for employed candidates)
8. the demand draft for the application fee of rs. 200/- or rs. 100/- as applicable
9. two letters of reference (for ph.d. applicants only)
the completed application form must reach on or before
april 16 for admission in july semester and november 12 for december semester

mailing address for applications:


the convenor, dpgc +
department/programme to which admission is sought:
indian institute of technology kanpur
kanpur - 208 016.
+
department post-graduate committee.

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