Indian Institute of Management Raipur - IIM Raipur

Indian Institute of Management Raipur
GEC Campus, Sejbahar, Raipur -492015 Phone: +91-771-2772115
Post Graduate Programme for Working Executives (PGPWE)
2012-14
Application Form
Please Note:
1. Please use CAPITAL letters only.
2. Use commonly used abbreviations for courses, degrees, certificates, university names, etc., where ever required.
3. This form is a key part of the admission process. Complete and accurate information are, therefore, extremely important.
Incomplete or false information will make your candidature null and void.
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. You are required to show all relevant testimonials in original at the time of Personal Interview, if you are short-listed for the
same.
6. The completed application form along with relevant document should be sent to – Administrative Officer (Admissions) Indian
Institute of Management Raipur, GEC Campus, Sejbahar, Raipur 492015 on or before September 14, 2012 through Speed
Post only.
7. Candidates are requested to remit the fees only through NEFT/RTGS mode of payment and in this regard our Banker details
are as follows:
Bankers Name
Union Bank of India
Branch Detail
Priyadarshini Branch, Raipur
Savings Bank A/c No 612702010001753
NEFT/ RTGS Code UBIN 0561274
MICR Code 492026009
(For Office Use Only)
Registration Number
_______________________________________________________________________________________________
A. Personal Data
A.1 Name: ______________________________________________________________
First Name Middle Name Last Name
A.2 Gender: Male Female A.3 Nationality: ________________
A.4 Date of Birth:
DD MM YYYY
A.5 Age as on 1 st October, 2012: Years: _________ Months: __________
Paste Recent
Passport Size
Photograph
A.6 Address:
Correspondence Address
Permanent Address
City: Pin City: Pin
State:
State:
Phone:
Phone:
Mobile:
Mobile:
A.7 E-mail Id: _________________________________________
A.8 Category: SC ST NC-OBC DAP General
(Attach copy of SC, ST, OBC, DAP certificate as applicable)
1

B. Academic Qualification
B.1 Academic Records:
Degree/
Examination
Subject
School /
Institution
Board /
University
Year
Completed
Max.
Marks
Total
Marks
Obtained
% Marks
Obtained
Class/
Dvn.
10 th
12 th
Graduation
Post
Graduation
Others
Enclose Photocopy of aforementioned marksheets
C. CAT/GMAT/BAT SCORE
C.1 If Applying Through CAT:
CAT (last 2years) - Test Registration No.
CAT SCORE: (Obtained in last 2 years)
Section 1
Quantitative Ability & Data
Interpretation
Section 2
Verbal Ability & Logical
Reasoning
Total
Score Percentile Score Percentile Score Percentile
Enclose Photocopy of CAT Score Card
C.2 If Applying Through GMAT:
OR
GMAT Score Report
(Score obtained last 2 years)
Test Date
Scaled Scores
Year
Verbal
score
%
Below
Quant
Score
%
Below
Total
Score
%
Below
AWA
Score
%
Below
Enclose Photocopy of GMAT Score card
C.3 If Applying Through BAT: Yes No
If yes, please choose your Test Centre* in preference of First, Second, Third, Fourth and Fifth)
OR
Bhilai Bilaspur Korba Raigarh Raipur
If sufficient candidates do not opt for a particular Test Centre, the Centre will be cancelled and the
candidate will be allotted next preferred Centre.
2

D. Work Experience
D.1 Total Work Experience as on 1 st October, 2012____years ____ months and __days (minimum 5 years of
managerial/ entrepreneurial/ professional experience after graduation.).
________________________________________________________________________________________
D.2 List all your work experiences in descending order (latest first) Use multiple lines as needed. (Do not
include training, project work, work done as an integral part of curricular requirement, and part time work.):
E.
Brief Job Profile
From
(DD/MM/YY)
To
(DD/MM/YY)
Total
Competed
Months
and Days
Name of the
Organisation
Designation
(In short)
Annual
Income
Approx.
(Rs.)
(Please enclose all work experience certificates and copy of the first & last salary slip)
D.3 Special Achievements:
3

E. Extra-Curricular Activities/Additional Information, if any
Please mention, within the space provided, inter-collegiate, Institute and higher level activities only. These
may include games and sports, cultural, literary and similar other activities:
F. Why do you want to join this Programme
Please state, within the space provided, aspects to strengthen your candidature for this programme:
Declaration
I certify that the particulars given by me in the application form are true to the best of my knowledge. I know that
at any time if the information furnished by me is found incorrect my candidature will be cancelled immediately.
I agree to abide by the decision of the institute authorities regarding my selection/non selection.
Place:
Date:
______________________________________
Signature of the Candidate
Enclosures with the Application Form:
1. Proof of Age
3. Photocopies of Degrees & Mark Sheets of class X, XII and graduation.
4. Photocopy of CAT/GMAT Score card, if applicable
5. Work Experience Certificate
4