2

M.Tech.
2012

FORM

M.Tech. Admission
Indian Institute of Technology Madras

M 05

Acceptance of Offer of Admission by the Candidate

Name of Candidate
(Block Letters)
M.Tech. Application No.
Address :

PIN Code
To
The Chairman
M.Tech Admission Committee
GATE Office, IIT Madras
Chennai 600036
Sir,
With reference to your letter No.IITM/M.Tech. Admn. 2012, dated _______ 2012, I hereby accept your
offer of admission to M.Tech programme in the stream ______________________________________.
I enclose the following:
(i)

Original GATE SCORE CARD based on which present offer has been made.
GATE Registration No.

(ii)

A Demand Draft (Rs.10550/- for General/OBC (Non-Creamy Layer) candidates and Rs.5550/for SC/ST candidates) towards Institute fee drawn in favour of The Registrar, IIT Madras,
payable at Chennai, the details of which are given below:
Amount
Rs.

(iii)

Demand
Draft No.

Date

Name of the Bank

Place of Issue

I am currently employed at (Organisation) ________________________________________

(location) _________________________________. I understand that I need to produce the
relieving order from the competent authority of the employer at the time of admission on
25th July, 2012, failing which the offer of admission will be cancelled.
I am not employed.

I shall be reporting to the Institute at Student Activities Centre (SAC) on Wednesday,

25th July, 2012 at 8.30 a.m. for admission.

Date:
Place:

Signature

M.Tech.
2012

M.Tech. Admission
Indian Institute of Technology Madras

FORM
M 06

DECLARATION by the Candidate

Name of Candidate
(Block Letters)

M.Tech. Application No.

Please tick [] any one of the options given below:

I do not wish to be considered for updating the M.Tech. stream

allotted to me.

I wish to be considered for updating the M.Tech. stream, if vacancy

arises.

Date :

Signature

M.Tech.
2012

FORM

M.Tech. Admission
Indian Institute of Technology Madras

M 07

DECLINING OFFER OF ADMISSION

Name of Candidate
(Block Letters)
M.Tech. Application No.
Address :

PIN Code
Tick whichever is applicable below:
I am declining the present offer (No. IITM/M.Tech. Admn. 2012 dated

).

I am declining the present offer (No. IITM/M.Tech. Admn. 2012, dated

).
However, I would like to be considered for the higher preferences (M.Tech.
Programme) as given in my application.

Place :
Date

To
The Chairman
M.Tech Admission Committee
GATE Office
IIT Madras
Chennai 600 036

Signature

M.Tech.
2012

M.Tech. Admission Committee

Indian Institute of Technology Madras

FORM
M 08

GENERAL INSTRUCTIONS AND ADMISSION SCHEDULE

I.

Reporting for Admission:

You are required to report for admission at the Student Activities Centre (SAC) of this
Institute and participate in the orientation programme as per the schedule given
overleaf.

II.

You must bring the following documents at the time of reporting for admission:

1.

Date of birth extract:

A photocopy of your SSLC / SSC / Matriculation certificate along with the original.

2.

Degree Certificate:
Originals of degree/provisional degree and Grade Cards/Mark Sheets of all the
semesters of your degree programme with one set of photo copies of the same.

3.

Declaration by Parent:
Declaration signed by your Parent/Guardian in the enclosed Form M 09.

4.

Medical Fitness Certificate:

Medical fitness certificate in the enclosed Form M 10.

5.

Draft for Hostel Deposit and Charges (Hostellers only):

A Demand Draft for Rs.16,842/- towards hostel deposit and charges drawn in favour of
The Chairman, Council of Wardens, IIT Madras payable at Chennai.

6.

Course Completion Certificate:

All the candidates admitted to M.Tech. programme at IIT Madras should have completed
all the examinations including Viva-voce by July 15, 2012. If the results of the final
examination are not yet announced, a Course Completion Certificate from the Head of
your Institution must be produced in Form M 11. Such candidates must submit the
Provisional Certificate on or before 30-09-2012.

7.

Relief Certificate:
Employed candidates must submit relief certificate from the employer at the time of
admission, failing which the offer of admission will be cancelled.

8.

Category Certificate:
SC/ST/OBC (Non-Creamy Layer) candidates should produce the original and a photocopy
of the category certificate issued by the Competent Authority.

9.

Hostel Accommodation:
Accommodation list will be displayed in the website (http://ccwoffice.iitm.ac.in) and on the
Notice Board of the Chairman, Council of Wardens (Ph.No: 044 2257 8500) located next to SAC
(Student Activities Centre) Building. On arrival, the students are requested to proceed to the hostel
allotted.
Chairman
M.Tech. Admission Committee
IIT Madras
(PTO)

M.Tech. Admission Schedule

Date & Day

Time

Programme

Venue

25.07.2012
(Wednesday)

09:30 hrs.
to
12:30 hrs.

Admission to M.Tech.

Student Activities
Centre (SAC)

Orientation Programme
09:00 hrs.

Welcome Function

09:45 hrs.

Coffee Break

10:00 hrs.

Chairman, Council of Wardens

Advisor-Sports / Cultural
Training and Placement Officer
Chief Medical Officer
Chief Advisor, MITr,
Advisor-Weaker Section &
Foreign Students
Academic Section Officers

26.07.2012
(Thursday)

27.07.2012
(Friday)
30.07.2012
(Monday)

Introduction of:

10:30 hrs.

Talk by Dean, Academic Courses, on

Credit
System,
Relative
Grading,
Evaluation Pattern, Registration etc.

14:00 hrs.

Visit to Department / Lab concerned /

Registration of courses for First Semester/
Meeting with HoD / Faculty Advisor

10.00 hrs.

English Diagnostic test

08:00 hrs.

Commencement of classes for the First

Semester

Student Activities
Centre (SAC)

Departments of IIT
Madras
CRC
Rooms as
indicated in the
Slot-wise list*

*To visit intranet http://academic.iitm.ac.in

Note: Students who wish to come one day earlier may do so and report to the Chairman,
Council of Wardens IIT Madras between 9.00 a.m. and 5.00 p.m. on 24-07-2012.

M.Tech.
2012

FORM

M.Tech. Admission
Indian Institute of Technology Madras

M 09

DECLARATION BY PARENT / GUARDIAN

[to be submitted at the time of Admission]

Name of Candidate
(Block Letters)
M.Tech. Application No.
To
The Chairman
M.Tech. Admission Committee
GATE Office
IIT Madras
Sir,
In the event of the applicant, my son / daughter / ward, being admitted to the M.Tech.
programme at Indian Institute of Technology Madras, I undertake to pay regularly the amounts
due from him/her to the Institute towards tuition fee, mess charges, hostel seat rent, etc.,
within the prescribed dates.
Place:
Date :
*
Signature of Parent/Guardian : ....

Name in Block Letters

: ....

Profession

: .....

Address

: ..
..
.....
.....
Pin Code

Phone No. with

STD Code

Office

Residence

Mobile

E-mail, if available

*
Note: In the case of guardian, please give the relationship in brackets below the signature.

M 10
CONFIDENTIAL

Medical History and Personal Particulars of Students joining at IIT Madras

1.

Full Name (in Block Letters) .

2.

Roll No.
..

3.

Name of Parent/Guardian

4.

Personal

Veg. / Non-Veg.

Abuse of substances (if any)

Smoking / Alcohol / Drugs / Any other

Past Medical/Surgical Treatment

5.

6.

7.

5.1

Allergies/Bronchial Asthma/Tuberculosis

5.2

Abdomen including Urinary Tract

5.3

Locomotor system (Spinal/Vertebral column/Joints)

5.4

Cardiovascular system

5.5

Neurological disorders/Psychological disorders

5.6

Sexually-transmitted/Venereal Diseases/Skin

5.7

Hepatitis

5.8

Diabetes

5.9

Rheumatism

5.10

Thyroid disease

Family history of any major illness

6.1

Tuberculosis

6.2

Leprosy

6.3

Diabetes

6.4

Hypertension

6.5

Ischemic heart diseases

6.6

Psychiatric illness

6.7

Cancer

Identification marks

No

Yes

No

Yes

1)
2)

8.

Blood Group

I declare that all the statements above are true and correct to the best of my knowledge. I fully understand
that I am responsible for the accuracy of all statements given.
Candidates Signature : ..
Counter signed by Parent/Guardian : .
Date :
Place :

:2:

HEALTH CERTFICATE
1. Examination by a General Physician (M.D. in General Medicine)

I, Dr. .. after examining

(with necessary investigations) Mr./Ms. .
Son / Daughter of Mr./Ms. ....
born on

CERTIFY:
Weight . Kg.

Height . cm.

Blood Pressure .. /. mm Hg.

Girth of Chest : (a) At rest . :

(b) After deep inspiration ..

Cardiovascular System

Heart Heart Sounds

Respiratory System

Neurological System

Psychological disturbance

Past Medical or Surgical Record

Identified allergies

Current treatments

Yes / No

If yes, specify

Current vaccination Status (All candidates who do not have adequate active/passive immunity against
diseases mentioned below should take these injections/adult booster dose as recommended, just before
joining the Institute and the date to be mentioned below):
VACCINATION AGAINST
DISEASES

1st Injection
Date
Yes / No

BCG
Diphtheria Tetanus - Poliomyelitis
Measles, Mumps, Rubella
Hepatitis B
Hepatitis A
Meningitis
Typhoid
Chicken Pox

Candidates Signature : .

Last Booster
Date
Yes / No

:3:

2. Examination by Ophthalmologist*
Acuity of
Vision

Far Vision
Naked Eye

With Glasses

Near Vision
Naked Eye

Colour Vision

With Glasses

R.E.
L.E.
*Latest Optometrists Recommendations, if any to be attached in original.
Remarks / Special Recommendation, if any :

I, Dr. ..... have examined

(with necessary investigations) Mr./Ms. . Son /
Daughter of Mr./Ms. ..... born
on and the above information given to the best of my knowledge are
correct and true.

Date :
Place :

Signature & Seal

3. Examination by ENT Specialist*

Inspection / hearing

*Audiometry

Right Ear
Left Ear

*Latest Audiometry report to be attached in original.

Remarks / Special Recommendations, if any.

I, Dr. ... have examined (with

necessary investigations) Mr./Ms. ... Son / Daughter
of Mr./Ms. ... born on and
the above information given to the best of my knowledge are correct and true.

Date :
Place :

Signature & Seal

Candidates Signature :

:4:

INVESTIGATIONS
1. *Electrocardiogram

Date ..

Result

2. *Chest X-ray

Date ..

Result

3. *Sonography (whole abdomen)

Date ..

Result

4. *Urine

Date ..

Result

5. *Blood Tests

Date ..

Result

a) Blood Sugar (F/PP)

Date ..

Result

b) Urea/Creatinine

Date ..

Result

c) Peripheral Smear Study/HB%

Date ..

Result

d) Lipid Profile

Date ..

Result

e) Blood Group/typing (if not known)

Date ..

Result

f) HBS Ag

Date ..

Result

g) HIV I & II

Date ..

Result

*All original investigation reports (only) to be attached.

Remarks / Special Recommendation, if any:

Conclusion : Fit / Unfit to pursue higher education with a very tight academic schedule.
Reason :

Date :
Place :

Signature & Seal

Candidates Signature : .

M.Tech.
2012

M.Tech. Admission
Indian Institute of Technology Madras

FORM
M 11

COURSE COMPLETION CERTIFICATE

Certified that Mr./Ms. , Roll No. . final
year student of this College, has completed all the requirements including practical,
project, Viva-voce, etc. for the award of the degree, and

a)

He/She has appeared for the final examination held during .. 2012, the
results of which are awaited.

b)

He/She has passed the final examination

(Strike out either (a) or (b) whichever is not applicable)

Place

Date

Signature & Name of Principal

with Office Seal

Name of the College :

University

NB: Selected candidate must have appeared for all the examinations including project viva for the
th
award of the qualifying degree by 15 July, 2012, otherwise the candidate is not eligible for
admission even if the offer of admission to M.Tech. is issued by IIT Madras.