INDIAN INSTITUTE OF MANAGEMENT INDORE

TWO-YEAR POST-GRADUATE PROGRAMME IN MANAGEMENT PGP 2011-13 BATCH AT Ras Al Khaimah, UAE Last date for receipt of application: August 10, 2011 INSTRUCTIONS
1. This application form is a key part of admission process and important for your selection. Complete and accurate information are, therefore, extremely important. Incomplete or false information will adversely affect your chances of selection. Admission granted on the basis of false and / or misleading information will be ipso facto null and void. In all matters relating to admission to the programme, the decision of the Institute's authorities will be final and binding on the applicant. No correspondence will be entertained from the applicant regarding his/ her non-selection. Please submit your application ONLINE on or before 10th August 2011. You are advised to take a hardcopy of the same and to submit at the time of BAT / interview as the case may be .In case of online submission, please ensure that all details are available in the related PDF format which can be mailed to admissions@gemgulf.com. In case of any difficulty hard copy option can be exercised. You may also submit your application through hard copy option. The copy may be downloaded and completely filled on for all details. This may be scanned and then sent to admissions@gemgulf.com .The Original hardcopy shall be produced at the time of BAT/ interview as the case may be. The application fee of AED 150 shall be transferred as per the details below Name; Global Education Mission FZ LLC Account no: 1014036928001 Swift code no: EBILAE AD

2. 3.

4.

Bank; Emirate NBD Bank, Corniche Branch, Ras Al Khaimah (UAE)

Remittance Details: Remitter name: ________________ Remitting Bank: ________________________ Date of Remittance_________________

Branch Location: _________________________

Remittance advice no ________________________ Amt; ___________________

(Please produce evidence of online fee payment at the time of BAT / Interview) (I) PERSONAL DATA Name of applicant: __________________________________________________________________ (In CAPITAL letters) As recorded in your academic certificates Name of applicant: ___________________________________________________________________ (In CAPITAL letters) As recorded in your Passport Date of Birth Day Marital status: Nationality Single Passport No. Month Married Issue Date Year Gender: Expiry Date Male Place of Issue Female Country of issue Age as on 30 June 2011 Years

Affix your recent passport size colour photograph here

Please give your complete mailing address;

Name: ______________________________________________________________________________________ (Last name or surname) (First Name) (Middle name/ initial)

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Address: Block: ___________________ City: ______________ Phone: (O) (R)

Aptt._________________________________ Street ___________ P O Box no _______ State __________________ Country ____________ Postal/Zip code_________________ Fax: Mob (O) (R) Email:

Name of Parents/ Guardian and ( relationship ) :

Contact number with complete code Mob Phone

Email

A. B.

(II) ACADEMIC QUALIFICATIONS Provide complete information on examination marks in all columns. Marks stated in these columns MUST MATCH those in the original mark sheets/transcripts. Wherever you have received letter grades or grade points instead of marks, provide equivalent marks and attach a certificate from competent authority explaining the method of conversion. Where such conversions are not possible, please provide an explanatory note in the additional space provided at the end of this page. The Admission Committee's decision in such cases would be final. Schooling: Standard Name of Board/ University Year of Passing Total Max. Marks/ Grade Total Marks/Grade Obtained % of Marks/Grade Obtained Class/ Division/ Rank*

1.

10th//Secondary/equiv. 12th//Higher secondary/equivalent a. Graduation _______________________________________ ________________________________________

Degree (B.A.,B.Tech. B.Sc.,etc.) Discipline (Engineering, Arts, Science, etc.)

Subject Specialization (Mechanical, Computer Sci. Literature, etc. ______________________________ Name of the University/Institution __________________________________________

Mode of Study (Full-time, Part-time, Distance education, etc.) __________________________________ Duration of your Bachelor Degree course 3 yrs 4 yrs 5 yrs

Total number of Years of education in English medium

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In the Table below, mention details of marks obtained by you in examinations of all subjects (including optional, subsidiary, internal, elective, minor, languages, etc.) taken in each year of the Bachelors Degree irrespective of whether these marks were considered for granting class/ divis ion. Year Year First Second Third Fourth Fifth Overall Space for explanation of letter grades/ grade points From Dates To Max. Marks/ GPA Marks/ GPA Obtained % of Marks Obtained No. of Attempts Rank* (if any)

*Please be prepared to produce certificates/ evidence if a rank is mentioned.

3.

Post Graduation (If applicable) Degree (M.A., M.Tech. M.S. etc.) Discipline (Engineering, Arts, Science, etc _____________________________________________ _____________________________________________

Subject Specialization (Mechanical, Computer Sci., Literature, etc ____________________________

Name of the University/Institution

_________________________________________________

Year 1st Year 2nd Year Month & Year of Examination

Dates From To

Max. Marks /GPA

Marks/ GPA Obtained

% of Marks Obtained

CGPA/CPI

Overall % marks obtained

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4.

Post-Graduate Professional Examination (if applicable) Give details of the last two professional examinations you have taken (e.g. Chartered Accountancy, Cost and Work Accountancy, Company Secretaryship etc.) University/ Institute registered with: ____________________________________________________________________________ Name of the course of study: __________________________________________________________________

Year Inter/ 1 st Year Final/ 2 nd Year Month & Year of Examination

Dates From To

Subjects taken at each level

Max. Marks

Marks Obtained

% Marks Obtained / CGPA/ CPI

Overall % marks obtained

University/ Institute registered with: __________________________________________________________________________ Name of the course of study: __________________________________________________________

==================

(III) GMAT/CAT /TOEFL SCORE DETAILS=============================

FOR GMAT BASED APPLICANTS

GMAT Score Report

Test Date Month Year Verbal score % Below Quant Score Scaled Scores % Total Below Score % Below AWA Score % Below

FOR CAT BASED APPLICANTS

CAT 2010 Score Report

Test Date Month Year Quantitative Percentile Scores Logical Reasoning and Data Interpretation Verbal Overall

ARE YOU A BUSINESS APTITUDE TEST (BAT) BASED APPLICANT?

Yes

No

Note: BAT will be administered on August 20, 2011 at UAE (if required) with a fee of US$150 payable online to IIM Indore. Please refer to admission procedure details for BAT eligibility.

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TOEFL SCORE DETAILS (Give as applicable) TOEFL Score Report- Internet Based Test (IBT) Month Year Reading Score Listening Score Speaking Score Writing Score Total Score

TOEFL Score Report- Paper Based Test (PBT) Month Year Listening Comprehension Score Structure and Written Expression Score Reading Comprehension Score Total Score

(IV) ACHIEVEMENTS a) Scholastic Achievements Please list scholastic awards or scholarships conferred on you during your graduation.

b)

Please describe your strengths and weaknesses that you have identified in yourself as a potential student for the programme. Restrict your response to four or five points.

(V) EMPLOYMENT RECORD Mention ONLY full-time, paid work experience after Graduation. Do not include training/ project work done as an integral part of any curricular requirement. Organization & Location with city and country Designation Joining date Leaving date Monthly Remuneration (US$) Reasons for leaving
( If applicable )

Total Work Experience as on June 30, 2011 In your present/ last job, briefly describe your job responsibilities, achievements and failures and lessons learnt.

Months

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VI ) DISCONTINUITY IN CAREER If work experience and academic/ professional qualifications do not account for the entire period from the time you completed the 10th standard till date, please specify the time gaps, with full explanation.

(VII ) EXTRA-CURRICULAR ACTIVITIES Indicate your extracurricular activities, which were won at district, state, and national levels

(VIII) CAREER PLANS Why do you wish to go in for a management career?

Besides management education, which area/ field would interest you most for a career and/ or for further education?

( IX ) MEDICAL HISTORY Please state whether you have any existing physical disability or any chronic illness, including mental illness, which could affect your studies at the Institute. If you have suffered from any chronic illness, including mental illness, in the past, please provide details below:

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Nature of illness 1. 2. 3.

When suffered

Date of completion of treatment

Remarks, if any

It is mandatory for all applicants to ensure that they are medically fit for joining the programme and they shall get the medical fitness certificate from authorised doctors/ hospitals preferably from Government Hospitals at the time of registration for the programme. As per UAE government rules, all applicants entering UAE on study /student visa provided as per UAE Immigration Laws have to be further tested for medical fitness and their final admission will be subject to medical clearance even though registered for the programme. The cost for the medical test will be borne by the applicant and will be included in the visa fee to be paid by the applicant if visa facilities are availed under the sponsorship of Global Education Mission, our collaborating partner in

Do you require VISA under GEM sponsorship?

Yes

No

Do you Facilities

require

Hostel

Yes

No

(X) DECLARATION I clearly understand that if I am selected, I will be allowed to join the programme only if I satisfy all requirements of the Institute including the submission of a certificate at the time of registration from Principal/ Registrar of my college/ institute that except for declaration of results, I have completed all requirements for obtaining the Bachelor's degree. And that I would have to produce evidence (mark sheet/ certificate) of having passed the Bachelor Degree on or before December 31, 2011. Non-fulfilment of these requirements will automatically result in the cancellation of the provisional admissions offer. I certify that the particulars given by me in this application form are true to the best of my knowledge and belief. I understand that admission granted on the basis of false and/ or misleading information will be ipso facto null and void. I agree to abide by the decision of the institute authorities regarding my selection/ non-selection for the programme. I also understand that commitment fee / registration fee which I may pay are non refundable and no claim will be made by me for the same. I undertake to produce the following documents at the time of BAT or Interview (as the case may be), if called for: a. Original and self attested copies of CAT 2010 /GMAT/TOEFL Scorecard b. Original and self attested copies of 3 letters of recommendation from teachers / employers c. A Statement of purpose d. Original and photocopy of the remittance advice evidencing payment of application fee e. 4 passport size photographs f. Original and self attested photocopies of all academic certificates / testimonials / marksheets / certificates from college/institute authorities evidencing proof of all claims made in this application. g. A duly filled and signed hard copy of this application (Downloaded in PDF format from web link) h. Resume

Place: ______________________

Date:______________________

_______________________________________________ Name and signature of the Applicant

PLEASE READ THIS FORM ONCE AGAIN AND MAKE SURE THAT YOU HAVE COMPLETED ALL THE DETAILS RELEVANT FOR YOU AND HAVE COMPLIED WITH ALL REQUIREMENTS. INCOMPLETE APPLICATION ARE LIABLE TO BE REJECTED
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