भारतीय �ौयो�गक� सं�थान पटना Indian Institute of Technology Patna

For Office Use: Sl. No. IITP/ACAD/M.TECH./2012/02/_________________

For Dept. Use: App. No.:_______________________________

(Fill the details of the Demand Draft drawn in favour of “IIT Patna” Payable at “Patna” for the Application Fee) Amount: Rs.

Draft No.:

Dated:

Drawn in Bank:

1. Full Name of the Applicant:

Affix your Recent

Passport size Photograph of size

4.5 cm X 3.5 cm

2. Father’s/ Guardian’s/Spouse’s Name: 3. Date of Birth (dd-mm-yyyy): 4. Nationality:

5. Gender: 6. Marital Status:

7. Category: General / OBC (including OBC Minorities) (Non-Creamy Layer) / SC / ST (In case of SC/ ST/ OBC (including OBC Minorities) (Non-Creamy Layer), enclose the attested copy of certificate for the proof of category in the prescribed format given in Annexure I,II or III, as applicable)

8. Are you a Person with Disability (PD)? Yes / No (If yes, enclose the attested copy of certificate from Govt. Medical Practitioner stating the type and percentage of physical disability)

9 (a). Contact Address: 9(b). Permanent Address:

9(c). Contact Phone Number: (In case of landline, write STD code also. Your Mobile phone number is preferable)

9(d). Contact Email Address:

10. Specialisation in which the candidate seeks M.Tech. admission is: 11. Are you also applying for M.Tech. to any other specialisation at IIT Patna? Yes / No If yes, list the names of other specialisations (Candidates applying for more than one specialisation should submit a separate

application for each programme): (A) (B) (C)

12. Seeking M.Tech. admission under the category: (Strike out(X) whichever is NOT applicable)

a) Regular & Full-Time. ( ) b) Sponsored & Full-Time ( )

13. Details of Academic Record (Attach attested copies of certificates, mark sheets, etc in support ) .

Degree/ Examination

Name of Institution/ Exam Board Year of Passing

Percentage of Marks/

CGPA/CPI*

Class/ Division

Obtained*

Subjects Taken

10th Class

12th Class

Graduation

Post- Graduation

(other degree)

* If degree is not obtained, write the percentage of marks or CGPA/CPI obtained up to the pre-final semester/ year.

14. Details of GATE examination passed*:

Exam Name GATE Paper GATE Score & Rank

Exam Passing Year

Valid upto

* Candidates must submit the attested photocopy for qualifying GATE examination.

15. Professional Experience, if any. (Attach attested copy of the proof). Name of Organization Position held Nature/ Type of Work Period (From – To)

A candidate presently working and applying for M.Tech. admission in sponsored category must provide a “No Objection Certificate” from the employer in the prescribed Performa “ Form - I” .

16. List of Publications/ Projects, if any. (Attach a separate sheet with details, if necessary. No of Papers published in Refereed Journals: ______, No. of Papers presented in Refereed Conferences:____

17. List of Enclosures

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. 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. I note that the decision of the Institute is final in regard to selection for admission and assignment to a particular department and field of study. Place: Date: Signature of the Applicant

Please note: For complete details (Areas of Specialisation etc.) on M.Tech. admission, visit the website: http://www.iitp.ac.in. Application Fee of Rs. 300/- (for Gen/OBC candidates) and Rs.150/- (for ST/SC/PD candidates) must be sent with this application by a demand draft drawn in favour of “Indian Institute of Technology Patna” and payable at Patna. The completed application enclosed with the demand draft for application fee and attested copies of mark sheets/certificates and with other necessary enclosures (if applicable) should be sent to the Assistant Registrar(Academic), Indian Institute of Technology Patna, Patliputra Colony, Patna – 800 013, Bihar, to reach on or before 14-05-2012. Please mark on the top of the envelope , Application for M.Tech. admission in “ Name of th e Specialisation ” . Incomplete application would be rejected without notification.

Form I No Objection Certificate

(This should be typed on the letter head of the relieving organization) Reference No.

Date: To, The Director Indian Institute of Technology Patna

Sub: NOC for M.Tech. Programme Dear Sir, We hereby sponsor the candidature of Mr./Ms./Mrs. ________________________________ who is an employee in our organization, for joining M.Tech. programme in ____________________________ at your Institute as a full-time student. We shall relieve him/her from his/her duties in the organization for two years of the M.Tech. programme.

Signature and Seal of the

Sponsoring Authority

ANNEXURE-I

FORM OF CERTIFICATE TO BE PRODUCED BY OTHER BACKWARD CLASSES APPLYING FOR APPOINTMENT TO POSTS / ADMISSION TO CENTRAL EDUCATIONAL INSTITUTIONS (CEIs), UNDER THE

GOVERNMENT OF INDIA

This is to certify that Shri/Smt./Kum. _____________________________ Son/Daughter of Shri/Smt.

__________________________________ of Village/Town ________________________________ District/Division

__________________________ in the _________________________ State belongs to the

________________________ Community which is recognized as a backward class under:

(i) Resolution No. 12011/68/93-BCC(C) dated 10/09/93 published in the Gazette of

India Extraordinary Part I Section I No. 186 dated 13/09/93. (ii) Resolution No. 12011/9/94-BCC dated 19/10/94 published in the Gazette of India

Extraordinary Part I Section I No. 163 dated 20/10/94. (iii) Resolution No. 12011/7/95-BCC dated 24/05/95 published in the Gazette of India

Extraordinary Part I Section I No. 88 dated 25/05/95. (iv) Resolution No. 12011/96/94-BCC dated 9/03/96. (v) Resolution No. 12011/44/96-BCC dated 6/12/96 published in the Gazette of India

Extraordinary Part I Section I No. 210 dated 11/12/96. (vi) Resolution No. 12011/13/97-BCC dated 03/12/97. (vii) Resolution No. 12011/99/94-BCC dated 11/12/97. (viii) Resolution No. 12011/68/98-BCC dated 27/10/99. (ix) Resolution No. 12011/88/98-BCC dated 6/12/99 published in the Gazette of India

Extraordinary Part I Section I No. 270 dated 06/12/99. (x) Resolution No. 12011/36/99-BCC dated 04/04/2000 published in the Gazette of India

Extraordinary Part I Section I No. 71 dated 04/04/2000. (xi) Resolution No. 12011/44/99-BCC dated 21/09/2000 published in the Gazette of India

Extraordinary Part I Section I No. 210 dated 21/09/2000. (xii) Resolution No. 12015/9/2000-BCC dated 06/09/2001. (xiii) Resolution No. 12011/1/2001-BCC dated 19/06/2003. (xiv) Resolution No. 12011/4/2002-BCC dated 13/01/2004. (xv) Resolution No. 12011/9/2004-BCC dated 16/01/2006 published in the Gazette of

India Extraordinary Part I Section I No. 210 dated 16/01/2006. Shri/Smt./Kum. ________________________________ and/or his family ordinarily reside(s) in the

__________________________ District/Division of ______________________State. This is also to certify that

he/she does not belong to the persons/sections (Creamy Layer) mentioned in Column 3 of the Schedule to the

Government of India, Department of Personnel & Training O.M. No. 36012/22/93-Estt.(SCT) dated 08/09/93

which is modified vide OM No. 36033/3/2004 Estt.(Res.) dated 09/03/2004.

Dated:

District Magistrate/

Deputy Commissioner, etc. Seal

Page - 6

NOTE:

(a) The term ‘Ordinarily’ used here will have the same meaning as in Section 20 of the Representation of the People Act, 1950.

(b) The authorities competent to issue Caste Certificates are indicated below: (i) District Magistrate / Additional Magistrate / Collector / Deputy Commissioner / Additional Deputy

Commissioner / Deputy Collector / Ist Class Stipendiary Magistrate / Sub-Divisional magistrate / Taluka Magistrate / Executive Magistrate / Extra Assistant Commissioner (not below the rank of Ist Class Stipendiary Magistrate).

(ii) Chief Presidency Magistrate / Additional Chief Presidency Magistrate / Presidency Magistrate.

(iii) Revenue Officer not below the rank of Tehsildar’ and (iv) Sub-Divisional Officer of the area where the candidate and / or his family resides.

ANNEXURE-II

Declaration/undertaking - for OBC Candidates only

I, __________________________ son/daughter of Shri ______________________ resident of village/town/city

____________ district _________________ State hereby declare that I belong to the _______________ community

which is recognized as a backward class by the Government of India for the purpose of reservation in services as per

orders contained in Department of Personnel and Training Office Memorandum No.36012/22/93- Estt. (SCT), dated

8/9/1993. It is also declared that I do not belong to persons/sections (Creamy Layer) mentioned in Column 3 of the

Schedule to the above referred Office Memorandum, dated 8/9/1993, which is modified vide Department of Personnel and

Training Office Memorandum No.36033/3/2004 Estt.(Res.) dated 9/3/2004.

Signature of the Candidate Place: Date: Declaration/undertaking not signed by Candidate will be rejected.

Page - 7

Annexure- III

DECLARATION / UNDERTAKING – BY OBC (NCL) - MINORITY CATEGORY CANDIDATES ONLY

I, ________________________________ son / daughter of Shri _________________________________ resident of________________________ village/town/city __________________________________ district ________________________ State _______________hereby declare that I belong to OBC(NCL) – MINORITY Category as notified by Central Government of India. I also declare that the condition of status / annual income for ‘Creamy Layer’ of my parents is within prescribed limits as on financial year ending on March 31, 2012. Based on this declaration I request you to kindly consider me as OBC(NCL) – minority. I will submit the attested copy of the certificate at the time of registration for the course. Signature of the Candidate Roll No. Place: Date: Signature of the Parent/Guardian (Declaration / undertaking not signed by candidate and countersigned by parents will be rejected) Place: Date:

Page - 8

DATA SHEET FOR THE APPLICANT (NAME): ……………………………………….. PROGRAMME: …………………………………………….

App. No. (For

Office Use)

Name & Address Category

Point 7 of the Application form

Specialisation for M.Tech. Programme

Academic Qualifications Experiences (For

employed Candidates)

Remarks (For Official

Use) Examination/

Degree

% of marks/ CGPA

Year in which

Completed

Name:

X

Mailing Address:

XII

Date of Birth

DD/MM/YYYY

B.E./ B.Tech/ B.Sc.

M.Sc.

Phone and Mobile Number:

Other Degree/Diploma (if any)

Email ID:

Category in Which Applied: (Regular/Sponsored)