Indian Institute of Science Bangalore - 560012

Instructions for Candidate

1. There are 3 sheets in this file. 2. Sheet 2 contains Application Form (to be sent to IISc along with enclosures). 3. Sheet 3 contains the address to which the application form has to be posted. Stick this sheet on top of the envelop containing the Application Package. 4. This Application Package should reach IISc on or before 07 May 2012. 5. Enclosures: 1. Application Form. 2. Attested copy of SC/ ST/ OBC (Other than Minorities)/ OBC (Minorities)/ PD / KM Certificates, (if applicable). 3. Photo copy of National Entrance Test Certificates such as KVPY - SA / KVPY - SB / KVPY - SX / IITJEE / AIEEE / AIPMT (as applicable). 4. Institute's copy of challan (if payment made by offline).

INDIAN INSTITUTE OF SCIENCE,

BANGALORE - 560012
APPLICATION FORM FOR ADMISSION TO

Application No

12711978

BACHELOR OF SCIENCE (BS) PROGRAMME 2012

Name of the Candidate : Mr. SRIMUKESSH S (as it appears in your SSLC/10th Standard Certificate) Gender : Category : Male Other Backward Class (Other than Minorities) (NCL) 24 Aug 1994 Tamil Nationality : Indian

Date of Birth : Mother Tongue : Address for Correspondence :

State of Domicile :

Tamil Nadu

PIN Code : E-mail Address : Phone Number :

16/16 The Safire Flat, 11th Avenue, Ashok Nagar, Chennai, Tamil Nadu 600083 muki_deepi@yahoo.com 04424853730 Mobile Number :

+91 - 9080468496

National Entrance Test Details : National Entrance Test IITJEE Educational Qualification : Schooling Year of Passing 10th Std 2010 Year 2012 Seat No. / Roll No. / Admit Card No. 6140398 Rank -

12th Std (Appeared/Appea ring)

2012

Institution / School Holy Cross Matriculation Higher Secondary School, Salem Maharishi Vidhya Mandir Senior Secondary School, Chennai

Board Tamil Nadu

% of Marks 96

Grade N/A

Subjects

CBSE

N/A

N/A

Chemistry,Mathematics,Physics,Engl ish,Computer Science

How did you come to know about the BS Programme :

Newspaper

Declaration : I hereby sincerely affirm that all the statements made and information furnished by me in the application form are true and correct.I agree to abide by the Rules and Regulations governing of Indian Institute of Science if admitted to the programme. I understand that I need to update the final roll No. and the rank of the entrance exam as and when it is made available (within one week), failing which my application my not be Processed. Place : Chennai

Date : 15/3/2012 Place : Chennai

Signature of the Applicant

Date : 15/3/2012
Submitted by Mr. SRIMUKESSH S on Mar 15 2012 11:13PM

Signature of Father/Mother/Guardian

IISc. Admissions 2012

Application Number : 12711978
BACHELOR OF SCIENCE (BS) PROGRAMME

From : Mr. SRIMUKESSH S 16/16 The Safire Flat, 11th Avenue, Ashok Nagar, Chennai, Tamil Nadu 600083

To : The Assistant Registrar (Academic) Admissions Unit Indian Institute of Science Bangalore - 560 012 Karnataka State.