INDIAN STATISTICAL INSTITUTE APPLICATION FOR ADMISSION : 2012-2013

(Read instructions carefully before lling in this form)

Form No. For Oce use only Stamp size Photograph Regn.No.

1. Full Name (in capital letters):

2. Address for Correspondence (in capital letters):

PIN Mobile no. 3. Course Code : 1st preference

(see page 38 of the Prospectus)

Tel.no.
(with STD code)

E-mail :................................................... 2nd preference

4. Centre Code : 1st preference 5. Age : 6. Sex : 7. Caste : Date of Birth : Male General Female SC day

2nd preference month (put ST

3rd preference year

in the appropriate box) OBC No (put (put in the appropriate box)

(see Section 4, pages 6 and 7 of the Prospectus)

Yes 8. Physical Disability (if any) : If yes, percentage of physical disability

(see Section 4, pages 6 and 7 of the Prospectus)

in the appropriate box)

9. Have you ever been admitted to a course at the Indian Statistical Institute? (put in the appropriate box) Yes 10. 11. 12. No If yes, Course(s) .............................. : ............................................ : ............................................ : ............................................ Session(s) ...................................... Occupation Occupation Occupation : ............................. : ............................. : .............................

Fathers Name Mothers Name Guardians Name

13. If you are employed (a) (b) (c) (d) (e) Employment Status Designation Employers Address Duration Experience, if any : ............................................................................ : ............................................................................ : ............................................................................ : ............................................................................ : ............................................................................

14. (a) Academic Records: Give details of all academic examinations in which you have passed/appeared indicating the % of marks/GPA and class in appropriate columns.
Examination (Please put in the appropriate box) Secondary/ (or equivalent) 10+2 years of Higher Secondary (or equivalent) Humanities (B.A.) Science (B.Sc.) Commerce (B.Com.) Engineering (B.E./B.Tech.) Humanities (M.A.) Science (M.Sc.) Commerce (M.Com.) Engineering (M.E./M.Tech.) Others (specify) University/ Board Year Subjects (indicate Hons./ Major Subjects) Total Marks (%)/GPA Math. Marks (%)/GPA Stat. Marks (%)/GPA Class/ Division

(b) Are you an INMO awardee? Yes

No

If yes, year of award No Appearing# in 2012 Total marks

(for B.Stat. (Hons.) and B. Math. (Hons.) only. See pages 9 and 11.)

(c) Do you have a valid GATE score? Yes

(for M.Tech. (CS) only)

If yes, then

All-India rank Subject

Percentile Year

* Must enclose one photocopy of his/her GATE score card containing all information mentioned in Item 14 (c) with this Application Form. # Must submit/send (i) one photocopy of his/her GATE score card containing all the information mentioned in Item 14 (c), and (ii) one photocopy of this Application Form mentioning the registration no. given by the Indian Statistical Institute, to the Dean of Studies by 10 April 2012. GATE Score for M.Tech. (CS) Applicant for 2012-13 must be written on top of the envelope containing these documents. (d) Academic Achievements, if any ........................................................................... ............................................................................................................................ (e) If you are yet to complete the qualifying examination, give the probable dates of (i) (ii) completion of the examination including practicals announcement of results ....................................... .......................................

15. Bank Draft No. (If you have downloaded this form) : ........................... Date: .................... Drawn on (Bank): .......................................................
Declaration to be signed by the applicant: The above particulars submitted by me are correct. If admitted, I shall not (a) leave in the middle of the course, (b) violate the discipline code of the Institute, and (c) indulge in any activity hampering the progress of my studies and spoiling the environment of the Institute.

Place : .................................

Signature of the applicant with date

Enclose the following with this Application Form : 1. Two self-addressed envelopes (not less than 10.5 X 5.5 ) without stamp. Self-address must be written in CAPITAL LETTERS with telephone number. 2. One self-addressed Acknowledgement Card axed with Rs. 6/-stamp, OR, one self-addressed Post Card (only if the application form has been downloaded from the website). The above items and the lled-in Application Form should be placed in the white envelope (supplied with the Prospectus) and then sent to the Dean of Studies, Indian Statistical Institute, 203 B.T. Road, Kolkata-700 108 by 5 March, 2012.