Form No.

APPLICATION FORM - PGDM

Reg. No. :

JAIPURIA INSTITUTE OF MANAGEMENT STUDIES

Shakti Khand-IV, Indirapuram, Ghaziabad-201012 (U.P.), India
Phone : +91-0120-488 1100 Mobile : 9717335551,9891788383
E-mail : pgdm@jaipuria.edu.in

Roll No. :

Instruction : Read the form carefully before filling.

Filling of the form does not ensure admission.
Admission will be confirmed only after receipt of full fees.
Refer to the checklist for submission of documents.
Pending documents, if any should be submitted within 15 days of taking admission.
Please submit a copy of photo identity proof and residential address proof.

Paste your
recent
stamp size
coloured
photograph

Name Mr./Ms.
Fathers Name
Mothers Name
Fathers Profession & Address
Company Name & Address:
Designation :

Qualification:

Phone No.:

Mobile No.:

E-mail.:
Mothers Profession & Address
Company Name & Address:
Designation :

Qualification:

Phone No.:

Mobile No.:

E-mail.:
Permanent Address with PIN Code

Phone No.:

Mobile No.:

E-mail.:
Present Address for Communication with PIN Code

Phone No.:

Mobile No.:

E-mail.:
Date of Birth DD
Sex

MM

YY

Marital Status

Category (SC/ST/OBC/GENERAL)
Hostel Accommodation Required

Yes

No

Academic Qualification
Name of Examination
High School
Intermediate (10+2)
Graduation
Any Other

Board/University/Institute

Year of passing

% Marks Obtained

Main Subject

APPLICATION FORM - PGDM

Entrance Examination Details

CAT

Roll No.

Score

Percentile

MAT

Roll No.

Score

Percentile

UPSEE

Roll No.

Score

Percentile

OTHERS

Roll No.

Score

Percentile

Professional Qualification Experience & Company Name

Period

Name of the Company

Position

Responsibility

How did you find out about Jaipuria Institute of Management Studies. Please specify the source.
Alumni: _______________________________________________(name)

Newspaper: ____________________________________________(name)

Friend/Relative/Parent: _________________________________(name)

Magazine: _____________________________________________(name)

Website: _____________________________________________(name)

Other(s), Pls. specify: ___________________________________(name)

Coaching Institute: ____________________________________(name)

Hobbies & Extra-curricular activites

Signature of Applicant
DECLARATION

I hereby declare that the information given in the application form is true to the best of my knowledge and belief. If any
information is found to be wrong, I shall be liable for action. I hold myself responsible for the due and prompt payment of fees.

Signature of Father/Guardian

Signature of Applicant

Name :...........................

Name :...........................

Date :...........................

For Admission Cell use only

Remarks
Admission Councellor
(Name)

Admission Incharge

For Office use only

The Candidate is eligible and admission is granted.

Academic Coordinator

Director

For Accounts Office use only

Received a sum of Rs..................................................(.....................................................................................................) vide Draft
No..............................................Dated ...............................Drawn on................................................... ..........................vide Receipt
No................................................................................Dated............................................

( Signature of Manager Accounts)

For use of Registrar office

ADMISSION OF THE CANDIdate is entered in records and Roll No._______________________is allotted.

Dy. Registrar

Registrar