Shri Shivaji Education Society Amravati’s

DR.. PANJABRAO DESHMUKH INSTITUTE OF MANGEMENT TECHNOLOGY & RESEARCH

DNC, Nagpur -440 012

Application form for Admission to P.G. Programme.

To Do Not Staple
The Director Paste Your
Dr. Panjabrao Deshmukh Institute of Latest
Management Technology & Reasearch Passport Size
Nagpur - 12 Photograph
Here

Sir,

I hereby apply for admission to Course

(Write in Capitals only)

1) Name :-

(As per University Degree)

(Tick at appropriate Box only)

2)Sex : Male Female

3) Date of Birth :
Date Month Year
4) Nationality : Indian Other
5) Marital Status : Married Unmarried

6) Category : Open SC ST OBC NT Other (Specify)

7) a) Educational Qualification (Which makes you eligible for the programme)

Qualification

Year of Passing

Percentage of Marks
B.Faculty Science Engineering Arts Commerce Pharma

Graduate

Post Graduate

Specify-Specification

8) a) Name of Last Examination passed

Year

b)Name of University

c) Enrolment No:-

( If already enrolled with Nagpur University)

9) a. Employment Status :

Unemployed Employed Self- Employed

b. Work experience( if any)

Duration :- Year Month

Name of Organization :

Designation :

10) Annual Income of Parents :-

Upto to Rs. 2,00,000 2 lakh to 3 lakh Above Rs. 3 lakh

11) (a) Address for Correspondence : ( Do not write Father’s or your name here)

City :

State:

Pin code :
(b) Telephone no. (with STD code)

Mobile Phone (if any)

(c) E-mail address(if any)