GITAM INSTITUTE OF SCIENCE GITAM (DEEMED TO BE UNIVERSITY)

(Established u/s 3 of UGC Act, 1956)

VISAKHAPATNAM-530045+Accredited by NAAC with 'A ' Grade"

GSAT- 2019APPLICATION FOR ADMISSION TO UG & PG SCIENCE PROGRAMS

Note: Read the instructions carefully before filling this form. This sheet should not be mutilated or folded or stapled. Apply separately for each test

Program applied

Application Number

1. Test Code:

Registration Number (For office use only)

2 Name of the test center:

3. Name of the Applicant (in capital letters)

Surname

Name

4. Name of the Parent/Guardian

5. Date of Birth

Day Month Year

9. Particulars of Qualifying Examination

(a) Qualifying Examination: _____________

(b) Result Status : Completed / Awaited

10. Particulars of fee paid : DD No. Date :

Amount : Bank :

STD Code Phone No. Mobile No.

Phone Number

Email ID :

11. Address for Communication (CAPITAL LETTERS only)

6. Sex

Male / Female

8. Reservation Category (if any)

SC/ST/PH/Others

( c ) Group Subjects:

Subject 1 ________________________

Subject 2 ________________________

Subject 3 ________________________

Address : .............................................................................

.............................................................................................

.............................................................................................

.......................................... Pin: ...........................................

Aadhaar No.

Signature of the Applicant

7.

Nationality :

State :

Affix Latest Passport size Photograph

Preferred Centers*: 1_________________________ 2._______________________ 3._____________________

Anantapur, Bhimavaram, Eluru, Guntur, Hyderabad, Kadapa, Kakinada, Khammam, Kurnool, Ongole, Rajahmundry, Srikakulam, Tirupathi, Vijayawada, Visakhapatnam, Warangal, Bengaluru, Berhampur, Bhubaneswar, Dhanbad, Guwahati, Jamshedpur, Kolkata, Nagpur, Patna, Pune,Raipur, Rayagada, Siliguri, Varanasi

*(Tests will be conducted at the above centers depending on the number of candidates opting for those centers. If sufficient number of candidates do not opt for a particular center, they will be allotted to the near by center)

Details of qualifying examinations:

School/College Title of the Degree/ Qualification

Max Marks

Marks Obtained

% CGPA

Year of Passing

X / SSC*

Inter / 10+2*

Undergraduate*

(* Specify Title of the Degree Awarded)

Documents to be enclosed:

th Original Demand Draft Copy of 10 Pass Certificate Copy of 10+2 Pass Certificate

Copy of Degree Marks Statement if available Aadhar Card

I came to know about GIS through

Newspaper TV Alumni EducationFairs Internet Hoardings

Direct Enquiry Counseled by GIS staff Current Student Faculty &Staff

Declaration: I hereby declare that all the particulars stated in this application are true to the best of my

knowledge and belief. In the event of submission of incorrect or untrue information, I understand that my

admission is liable for cancellation. Further I understand that my admission is purely provisional and subject to

the fulfillment of the eligibility conditions. There will be no refund of Application Fee for any reason. I agree to

receive communication through SMS related to admission process. I shall abide by the rules and regulations of

GITAM (DEEMED TO BE UNIVERSITY).

Signature of the applicant with date

SIGNATURE OF PARENT/GUARDIAN

GITAM INSTITUTE OF SCIENCE GITAM (DEEMED TO BE UNIVERSITY)

(Established u/s 3 of UGC Act, 1956)Gandhinagar Campus, Rushikonda, Visakhapatnam-530045, A.P., India

0891-2840450/452 / 2790101, Telefax: 0891 – 2790032, website: www.gitam.edu+Accredited by NAAC with 'A ' Grade"

GITAM INSTITUTE OF SCIENCE GITAM (DEEMED TO BE UNIVERSITY)

(Established u/s 3 of UGC Act, 1956)Gandhinagar Campus, Rushikonda, Visakhapatnam-530045, A.P., India

0891-2840450/452 / 2790101, Telefax: 0891 – 2790032, website: www.gitam.edu+Accredited by NAAC with 'A ' Grade"

DUPLICATE

ORIGINAL

Program :

Test Code :

Test Centre :

Date of Examination

Name of the candidate

(in capital letters) ____________________________________________

Name of the Parent / Guardian ____________________________________________

Signature of the candidate ____________________________________________

Program :

Test Code :

Test Centre :

Date of Examination

Name of the candidate

(in capital letters) ____________________________________________

Name of the Parent / Guardian ____________________________________________

Signature of the candidate ____________________________________________

Hall Ticket No (to be filled in by the office)

Hall Ticket No (to be filled in by the office)

Recent Passport size Photograph

Recent Passport size Photograph

GSAT -2019GITAM Science Admission Test

UG & PG Programmes for the academic year 2019 - 20

HALL TICKET

GSAT -2019GITAM Science Admission Test

UG & PG Programmes for the academic year 2019 - 20

HALL TICKET