INDIAN INSTITUTES OF MANAGEMENT
RAIPUR, RANCHI, ROHTAK & TRICHY
PERSONAL DATA FORM
POST-GRADUATE PROGRAMME IN MANAGEMENT 2011-13 BATCH
INSTRUCTIONS
1. Complete the form in CAPITAL letters only.
2. This form is a key part of admission process. Complete and accurate response to the items are, therefore,
extremely important. Incomplete or false information will make your candidature null and void.
3. For letter grades or grade points instead of marks, provide equivalent marks and attach a certificate from the
Registrar / Principal / Head of the Department explaining the method of conversions.
4. In all matters relating to admission, the decision of the Institute will be final and binding on the applicants.
No correspondence will be entertained from the applicant regarding his/her non-selection.
5. Submit this form along with other testimonials when you will come for Personal Appearance (PI) process
Shortlisted for IIM
(Please write the name of IIMs for which you have been shortlisted)
CAT Registration No.
A. PERSONAL DATA
1. Name_________________________________________________________________
Affix your
2. Date of Birth RECENT
d d m m y y y y Passport size
Photograph
3. Address for _____________________________________________________
correspondence
_____________________________________________________
PIN_______________________________E-mail id:___________________________________________________
4. Contact Telephone No. with STD Code___________________________ Mobile No.___________________________
5. Annual Parental Income Rs. 6. Nationality
7. Category (Pl. tick) SC 8. Phy. Handicapped (pl. tick) 9. Sex (pl. tick)
ST 1 Low Vision/Blindness
M F
NC-OBC 2 Hearing Impairment
GEN 3 Locomotor Disability/Cerebral Palsy
B. ACADEMIC QUALIFICATIONS
B1. Pre-Bachelor’s Degree Examination(s)
A. Fill only if a Board or a University Examination.
B. Take into account only the marks in the subjects/papers which are counted for awarding class/division.
Standard Board/University Year Max Marks Marks Class/ % of Marks
Obtained Division Obtained
10th
12th
EDUCATIONAL BACKGROUND : (Pl. Tick )
AGRI ARTS COMM ENGG SCI OTHERS
Please turn over
B2. Bachelor’s Degree Examination(s)
DegreeSought________________________________Subject/Specialization_______________________________________
College/Institute______________________________ University _______________________________________________
Year Date Marks considered for award of Class/Division in Bachelor’s degree
From To Max.Marks/GPA Marks/GPA Obtained % of Marks Obtained
1st Year
2nd Year
3rd Year
4th Year
5th Year
Total / CGPA
Class / Division Obtained
If you are appearing for the final year Bachelor’s
Degree examination, indicate the time of examination Month Year
If you have already completed the Bachelor’s Degree
Examination, indicate month/year of completion Month Year
B3 Master’s Degree / Post-Graduation / Professional Qualification
(College/University/Institute attended)________________________________________________________________
Year Subject Max. Marks % of Marks
From To Marks Obtained Obtained
1st Year
2nd Year
3rd Year
Overall percentage of marks obtained
C. WORK EXPERIENCE *
(Do not include training, project work, work done as an integral part of curricular requirement, and part time work.)
Organization Designation From To Monthly Reasons for leaving
Remuneration
(Rs.)
DD MM YY DD MM YY
Nature of Responsibility_________________________________________________________
Total work experience (in months) as on 31 Jan. 2011
* Please bring the total experience certificates and the copies of the all salary slips at the time of interview.
D. EXTRA-CURRICULAR ACTIVITIES
Please mention inter-collegiate, Institute and higher level activities only. These may include games and sports, cultural,
literary and similar other activities.
____________________________________________________________________________________________________
____________________________________________________________________________________________________
E. DECLARATION
I have carefully read the instructions and agree to abide by the decision of the institute’s authorities regarding my
selection for the programme. I certify that the particulars given by me in this form are true to the best of my
knowledge and belief.
Place:____________________
Date: ____________________ ____________________________________
Signature of Applicant
PLEASE EXAMINE THIS FORM ONCE AGAIN AND MAKE SURE THAT YOU HAVE COMPLETED ALL THE ITEMS
