Your IP : 216.73.216.40
<center><h2>Online Applicantion Form For M. Tech. (IT) 2012-2013 </h2></center>
<form action="appform.php?$email" method="post">
<!--<form action="index.php" method="post"> -->
<?php
require_once('classes/tc_calendar.php');
//include "functions.inc";
//dbConnect();
$db_con = mysql_connect('localhost','root','tiwss2011');
mysql_select_db('pgentrance');
$tbl = 'tbl_registration';
$fullname = $_POST["fullname"];
$dob = $_POST["dob"];
$pob = $_POST["pob"];
$gender = $_POST["gender"];
if (!$gender) $gender = 'Male';
$mstatus = $_POST["mstatus"];
if (!$mstatus) $mstatus = 'Unmarried';
$nationality = $_POST["nationality"];
$fathername = $_POST["fathername"];
$address = $_POST["address"];
$state = $_POST["state"];
$pincode = $_POST["pincode"];
$phone = $_POST["phone"];
$fax = $_POST["fax"];
$email = $_POST["email"];
$photo = $_POST["photo"];
$ddamount = $_POST["ddamount"];
$ddnumber = $_POST["ddnumber"];
$dddate = $_POST["dddate"];
$bankbranch = $_POST["bankbranch"];
$stream = $_POST["stream"];
$category = $_POST["category"];
if (!$category) $category = 'GEN';
$ge_name = $_POST["ge_name"];
$ge_discipline = $_POST["ge_discipline"];
$ge_rank = $_POST["ge_rank"];
$ge_year = $_POST["ge_year"];
$qd_uinversity = $_POST["qd_university"];
$qd_discipline = $_POST["qd_discipline"];
$qd_degree = $_POST["qd_degree"];
$qd_examdate = $_POST["qd_examdate"];
$qd_finalresultsexpectedby = $_POST["qd_finalresultexpectedby"];
$qd_minmarks = $_POST["qd_minmarks"];
$qd_overallgrade = $_POST["qd_overallgrade"];
$we_datefrom1 = $_POST["we_datefrom1"];
$we_dateto1 = $_POST["we_dateto1"];
$we_employer1 = $_POST["we_employer1"];
$we_position1 = $_POST["we_position1"];
$we_nature1 = $_POST["we_nature1"];
$we_datefrom2 = $_POST["we_datefrom2"];
$we_dateto2 = $_POST["we_dateto2"];
$we_employer2 = $_POST["we_employer2"];
$we_position2 = $_POST["we_position2"];
$we_nature2 = $_POST["we_nature2"];
$we_datefrom3 = $_POST["we_datefrom3"];
$we_dateto3 = $_POST["we_dateto3"];
$we_employer3 = $_POST["we_employer3"];
$we_position3 = $_POST["we_position3"];
$we_nature3 = $_POST["we_nature3"];
$remoteip = $_SERVER["REMOTE_ADDR"];
if ($_POST["submit"] == 'SUBMIT') {
mysql_query("insert into $tbl(id,fullname,dob,pob,gender,mstatus,nationality,fathername,address,state,pincode,phone,fax,email,photo,ddamount,ddnumber,dddate,bankbranch,stream,category,ge_name,ge_discipline,ge_rank,ge_year,qd_university,qd_discipline,qd_degree,qd_examdate,qd_finalresultexpectedby,qd_minmarks,qd_overallgrade,we_datefrom1,we_dateto1,we_employer1,we_position1,we_nature1,we_datefrom2,we_dateto2,we_employer2,we_position2,we_nature2,we_datefrom3,we_dateto3,we_employer3,we_position3,we_nature3,date_creation,date_modification,remoteip)
values(NULL,'$fullname','$dob','$pob','$gender','$mstatus','$nationality','$fathername','$address','$state','$pincode','$phone','$fax','$email','$photo','$ddamount','$ddnumber','$dddate','$bankbranch','$stream','$category','$ge_name','$ge_discipline','$ge_rank','$ge_year','$qd_uinversity','$qd_discipline','$qd_degree','$qd_examdate','$qd_finalresultexpectedby','$qd_minmarks','$qd_overallgrade','$we_datefrom1','$we_dateto1','$we_employer1','$we_position1','$we_nature1','$we_datefrom2','$we_dateto2','$we_employer2','$we_position2','$we_nature2','$we_datefrom3','$we_dateto3','$we_employer3','$we_position3','$we_nature3',now(),now(),'$remoteip')");
/* echo " mysql_query(insert into $tbl(id,fullname,dob,pob,gender,mstatus,nationality,fathername,address,state,pincode,phone,fax,email,photo,ddamount,ddnumber,dddate,bankbranch,stream,category,ge_name,ge_discipline,ge_rank,ge_year,qd_university,qd_discipline,qd_degree,qd_examdate,qd_finalresultexpectedby,qd_minmarks,qd_overallgrade,we_datefrom1,we_dateto1,we_employer1,we_position1,we_nature1,we_datefrom2,we_dateto2,we_employer2,we_position2,we_nature2,we_datefrom3,we_dateto3,we_employer3,we_position3,we_nature3,date_creation,date_modification,remoteip)
values(NULL,'$fullname','$dob','$pob','$gender','$mstatus','$nationality','$fathername','$address','$state','$pincode','$phone','$fax','$email','$photo','$ddamount','$ddnumber','$dddate','$bankbranch','$stream','$category','$ge_name','$ge_discipline','$ge_rank','$ge_year','$qd_uinversity','$qd_discipline','$qd_degree','$qd_examdate','$qd_finalresultexpectedby','$qd_minmarks','$qd_overallgrade','$we_datefrom1','$we_dateto1','$we_employer1','$we_position1','$we_nature1','$we_datefrom2','$we_dateto2','$we_employer2','$we_position2','$we_nature2','$we_datefrom3','$we_dateto3','$we_employer3','$we_position3','$we_nature3',now(),now(),'$remoteip') ";
*/
}
/*if ($_POST("submit") == 'PRINT'){
//header("Location: http://pgentrance.iiita.ac.in/appform.php?$email");
}*/
echo "
<table>
<tr><td>
<table><tr><td width=20%>Full Name </td><td width=80%>
<input type='text' name='fullname' size='50' maxlength='50' value='$fullname'>
</td></tr><tr><td>Date of Birth (MM-DD-YYYY)
</td><td>
<input type='text' name='dob' size='50' maxlength='100' value='$dob'>
</td></tr><tr><td>Place of Birth
</td><td>
<input type='text' name='pob' size='50' maxlength='50' value='$pob'>
</td></tr><tr><td>Gender
</td><td>
";
$genders = array("Male","Female");
foreach ($genders as $gen) {
echo "<input type='radio' name='gender' value='$gen'";
if ($gen == $gender) echo " checked";
echo "> $gen ";
}
echo "
</td></tr><tr><td>Marital Status
</td><td>";
$mstatuss = array("Unmarried","Married");
foreach ($mstatuss as $mstat) {
echo "<input type='radio' name='mstatus' value='$mstat'";
if ($mstat == $mstatus) echo " checked";
echo "> $mstat ";
}
echo "
</td></tr><tr><td>Nationality
</td><td>
<input type='text' name='nationality' size='50' maxlength='150' value='$nationality'>
</td></tr><tr><td>Father Name
</td><td>
<input type='text' name='fathername' size='50' maxlength='150' value='$fathername'>
</td></tr><tr><td>Address for Correspondance
</td><td>
<textarea name='address' rows='3' cols='50' maxlength='150' value='$address' >$address</textarea>
</td></tr><tr><td>State
</td><td>
<select name='state'>";
$states = array('Andaman & Nicobar','Andhra Pradesh','Arunachal Pradesh','Assam','Bihar','Chandigarh',
'Chhattisgarh','Dadra & Nagar Haveli','Lakshadweep','Madhya Pradesh','Maharashtra','Manipur','Meghalaya','Mizoram',
'Nagaland','Orissa','Daman & Diu','Delhi','Goa','Gujarat','Haryana','Himachal Pradesh','Jammu & Kashmir',
'Jharkhand','Karnataka','Kerala','Puducherry','Punjab','Rajasthan','Sikkim','Tamil Nadu','Tripura',
'Uttar Pradesh','Uttarakhand','West Bengal');
foreach ($states as $stat) {
echo "<option value='$stat'";
if ($stat == $state) echo " selected";
echo ">$stat</option>";
}
echo "</select>
</td></tr><tr><td>Pin Code
</td><td>
<input type='text' name='pincode' size='50' maxlength='50' value='$pincode'>
</td></tr><tr><td>Phone No.
</td><td>
<input type='text' name='phone' size='50' maxlength='50' value='$phone'>
</td></tr><tr><td>FAX No.
</td><td>
<input type='text' name='fax' size='50' maxlength='50' value='$fax'>
</td></tr><tr><td>Email Address
</td><td>
<input type='text' name='email' size='50' maxlength='50' value='$email'>
</td></tr>
</table>
</td> <td valign=top>
<imgsrc='photos/'.$photo.' height=120 width=120 /><br>
Upload your photograph<sup>@</sup> (.jpg only)<br><br>
<input type='file' name='photo' size='30' > <br><br>
</td></tr>
<tr><td colspan=2><hr>
<b>Application Fee</b> 1.) For Online payment <a href='payhdfc.html'>CLICK HERE</a><br>
2.) Details of Demand Draft/Cash Receipt
<br>
</td></tr><tr><td colspan=2>
<table>
<tr><td> a) Amount Rs.
<input type='text' name='ddamount' size='50' maxlength='50' value='$ddamount'>
</td><td>DD No.
<input type='text' name='ddnumber' size='50' maxlength='50' value='$ddnumber'>
</td><td>Dated
<input type='text' name='dddate' size='50' maxlength='50' value='$dddate'>
</td></tr>
<tr><td colspan=3>b) Bank & Branch issued
<input type='text' name='bankbranch' size='165' maxlength='165' value='$bankbranch'>
</td></tr>
</table>
<hr>
</td></tr>
<tr><td colspan=2> Stream
<input type='text' name='stream' size='50' maxlength='50' value='$stream'>
</td></tr><tr><td>Category
";
$categories = array("GEN","SC","ST","PH","SN","NR","OB");
foreach ($categories as $cat) {
echo "<input type='radio' name='category' value='$cat'";
if ($cat == $category) echo " checked";
echo "> $cat ";
}
echo "
</td></tr>
<tr><td colspan=2>
<hr>
<b>GATE exam details<sup>#</sup> Not for MBBS/BVSc & AH/Sponsored candidates. GRE details for NRI/FN Candidates.</b>
</td></tr>
<tr><td colspan=2>
<table>
<tr><td>Exam Name </td>
<td>Exam Discipline </td>
<td>Exam Year </td>
<td>Rank/Score </td>
</tr>
<tr><td><input type='text' name='ge_name' size='50' maxlength='50' value='$ge_name'> </td>
<td><input type='text' name='ge_discipline' size='50' maxlength='50' value='$ge_discipline'> </td>
<td><input type='text' name='ge_year' size='50' maxlength='50' value='$ge_year'> </td>
<td><input type='text' name='ge_rank' size='50' maxlength='50' value='$ge_rank'> </td>
</tr>
</table>
</td></tr>
<tr><td colspan=2>
<hr>
<b>Qualifying Degree<sup>#</sup> already obtained or in progress</b>
</td></tr>
<tr><td colspan=2>
<table>
<tr><td>University/Institute</td>
<td>Discipline</td>
<td>Degree</td>
<td>Exam Date</td>
<td>Final results expected by <br> (if degree not completed)</td>
<td>Min. Pass Marks, % or <br>Grade Average</td>
<td>Overall % or Grade Average<br> (if degree completed)</td>
</tr>
<tr><td><input type='text' name='qd_university' size='25' maxlength='25' value='$qd_university'> </td>
<td><input type='text' name='qd_discipline' size='25' maxlength='25' value='$qd_discipline'> </td>
<td><input type='text' name='qd_degree' size='25' maxlength='25' value='$qd_degree'> </td>
<td><input type='text' name='qd_examdate' size='25' maxlength='25' value='$qd_examdate'> </td>
<td><input type='text' name='qd_finalresultexpectedby' size='25' maxlength='25' value='$qd_finalresultexpectedby'> </td>
<td><input type='text' name='qd_minmarks' size='25' maxlength='25' value='$qd_minmarks'> </td>
<td><input type='text' name='qd_overallgrade' size='25' maxlength='25' value='$qd_overallgrade'> </td>
</tr>
</table>
</td></tr>
<tr><td colspan=2>
<hr>
<b>Working Experience<sup>*</sup> (if applicable latest three only)</b>
</td></tr><tr><td colspan=2>
<table>
<tr><td colspan=2 align='center'>Dates (From -To)</td><td>Employer</td><td>Position</td><td>Nature of Work</td></tr>
<tr><td><input type='text' name='we_datefrom1' size='20' maxlength='20' value='$we_datefrom1'></td>
<td><input type='text' name='we_dateto1' size='20' maxlength='20' value='$we_dateto1'></td>
<td><input type='text' name='we_employer1' size='50' maxlength='50' value='$we_employer1'></td>
<td><input type='text' name='we_position1' size='50' maxlength='50' value='$we_position1'></td>
<td><input type='text' name='we_nature1' size='50' maxlength='50' value='$we_nature1'></td>
</tr>
<tr><td><input type='text' name='we_datefrom2' size='20' maxlength='20' value='$we_datefrom2'></td>
<td><input type='text' name='we_dateto2' size='20' maxlength='20' value='$we_dateto2'></td>
<td><input type='text' name='we_employer2' size='50' maxlength='50' value='$we_employer2'></td>
<td><input type='text' name='we_position2' size='50' maxlength='50' value='$we_position2'></td>
<td><input type='text' name='we_nature2' size='50' maxlength='50' value='$we_nature2'></td>
</tr>
<tr><td><input type='text' name='we_datefrom3' size='20' maxlength='20' value='$we_datefrom3'></td>
<td><input type='text' name='we_dateto3' size='20' maxlength='20' value='$we_dateto3'></td>
<td><input type='text' name='we_employer3' size='50' maxlength='50' value='$we_employer3'></td>
<td><input type='text' name='we_position3' size='50' maxlength='50' value='$we_position3'></td>
<td><input type='text' name='we_nature3' size='50' maxlength='50' value='$we_nature3'></td>
</tr>
</table>
</td></tr>
<tr><td><br>
<input type='submit' name='submit' value='SUBMIT'>";
if ($email){
echo "<input type='submit' name='print' value='PRINT'>";
}
echo "
</td></tr></table>
";
/* $myCalendar = new tc_calendar("date3", true, false);
$myCalendar->setIcon("images/calendar.gif");
$myCalendar->setDate(date('d'),date('m'),date('y'));
$myCalendar->setPath("classes/");
$myCalendar->setYearInterval(1970, 2020);
$myCalendar->setAlignment('left', 'top');
$myCalendar->setDatePair('date3', 'date4', $date4_default);
$myCalendar->setDateFormat('j F y');
//$myCalendar->writeScript();
//$myCalendar = new tc_calendar("date4", true, false);
//$myCalendar->setIcon("images/calendar.gif");
//$myCalendar->setDate(date('d', strtotime($date4_default))
// , date('m', strtotime($date4_default))
// , date('Y', strtotime($date4_default)));
//$myCalendar->setPath("classes/");
//$myCalendar->setYearInterval(1970, 2020);
//$myCalendar->setAlignment('left', 'bottom');
//$myCalendar->setDatePair('date3', 'date4', $date3_default);
//$myCalendar->writeScript();
*/
?>
<br>
@ Scanned copy of attested Photograph can be uploaded on the online application form.<br>
# Attach attested copies of certificates, marks sheet etc. See checklist below for certificates required.<br>
* A candidate presenetly working (including those on projects) must provide a "No Objection / Relieving certificate" from the employer.<br>
<hr>
</form>