Application Form

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Indian Institute of Technology Guwahati

Application Form for Admission to MTech/MDes Programme

1. Application Number : 2. Applicant Name : 3. Gender : 4. Father/Guardian Name : 5. Date of Birth : 6. Marital Status : 7. Nationality : 8. Caste Category : 9. Student Category : 10. Any Qualifying degree from IIT's

9933 Ishan MALE SHRIMAN NARAYAN GUPTA 1989-07-05 SINGLE Indian General Physically Disable : NO Regular YES Applicant's Photo Mahajan

11. Correspondence Address :

House Number 64 Apna Vihar Kunjwani JammuJammu and Kashmir -180010 Vill./Town/City:- Jammu State:- Jammu and Kashmir Pincode:- 180010 STD code:Telephone Number:Fax Number:Email:- mahanishan7@gmail.com Mobile Number:- 9419138853

12. Permanent Address :

House Number 64 Apna Vihar Kunjwani JammuJammu and Kashmir -180010 Vill./Town/City:- Jammu State:- Jammu and Kashmir Pincode:- 180010 STD code:Telephone Number:Fax Number:Email:- mahanishan7@gmail.com Mobile Number:- 9419138853

Department: Preference 1: 13. Applicant's Choices : Preference 2: Preference 3: Preference 4:

Electronics and Electrical Engineering VLSI Communications Engineering Power and Control Signal Processing

14. Academic Record : Sl No. 1. 2. 3. Exam Name Class 10th OR Equi. Class 12th OR Equi. B-tech Board/University J K Public School/C.B.S.E Kalka Public School/C.B.S.E %/CGPA/CPI 77 69 Grade Format % out of 100 % out of 100 Subjects Taken Math,Hindi,English,Science,SST Year of Passing 2005 Status Passed Passed Passed

Math,Physics,Chemistry,English,Physical 2007 Education 2011

Shri Mata Vaishno Devi 8.13 University

CPI out of Electronics and Communication 10

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Application Form

https://auto.iitg.ernet.in/mtechmdes/print_application_de...

15. Professional Experience : Sl No. 1. Name Of Organization IBM Pvt Ltd Position Held Storage Administrator Type Of work Administrator Start Date 2011-06-20 End Date 2013-04-10

16. List Of Publications : Sl No. Title of Paper Name Of Author(s) Journal Name Volume Year of Publishing

17. Demand Draft : Demand Draft [ (Rs.150/- for Gen/OBC candidates) and (Rs.75/- for SC/ST/PD candidates) ] will be required at the time of Written Test and/or Interview, if called for. Please see details about it in 'Application Procedure'. 18. PROFESSIONAL QUALIYING EXAMS PASSED(GATE/CEED/NET) : GATE :: Discipline : EC Marks:48 Score:524 19. List of Enclosures : Uploaded Last Qualifying Examination Marksheet. Uploaded Last Qualifying Examination Certificate. Attested copies of all supporting documents will be required at the time of Written Test and/or Interview, if called for.Please see details about it in 'Application Procedure'. Rank:4095 Valid Up To:2015-03-14

Declaration I hereby declare that the entries made in this application form are correct to the best of my knowledge and belief. If selected for admission, I promise to abide by the rules and regulations of the Institute. I note that the decision of the Institute is final in regard to selection for admission and assignment to a particular Department/Centre and field of study. The Institute shall have the right to take any action it deems fit, including expulsion, against me at any time after my admission, if it is found that any information furnished by me is incorrect. Place : Date : Signature

2012 IITG Office Automation | IIT Guwahati

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