INDIAN INSTITUTE OF MANAGEMENT LUCKNOW
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1 INDIAN INSTITUTE OF MANAGEMENT LUCKNOW Prabandh Nagar, IIM Rad, Lucknw, Uttar Pradesh 603 Fellw Prgramme in Management (FPM) 0th Batch Admissin-09 INSTRUCTIONS This Frm is a key part f the Admissin Prcess. Incmplete r false infrmatin will make yur candidature null and vid. Befre filling this applicatin frm read the instructins and Prgramme details prvided nline at http// Fill in the Applicatin Frm in CAPITAL letters nly. An applicant is eligible t submit applicatins t a maximum f tw areas. Candidates applying t tw areas are required t submit tw separate applicatin frms, with all supprting dcuments, that shuld be sent tgether. Please enclse self-attested cpies f all applicable educatinal, wrk experience, caste, and physical disability certificates alng with each set f the frm. Als enclse a cpy f the dcument relevant t the eligibility criteria. If shrtlisted, all certificates (riginals) shuld be prduced at the time f interview. The frm shuld be cmplete in all respects. Incmplete frms will nt be cnsidered. Strike ut whichever prtin is nt applicable. Please pay the applicatin fee f Rs.,000/- (Rs.500/- fr ST/ST Candidates) nline. The applicatin fee cvers the fee fr applying t tw areas. In all matters relating t admissin, the decisin f the Institute will be final and binding n the applicants. N crrespndence will be entertained frm the applicant regarding his/her nn-selectin. Phtgraph PERSONAL DETAILS (Write/ tick the crrect chice in the crrespnding cell). Name. Date f Birth (DD/MM/YYYY) 3. Gender Male/ Female/ Transgender 4. Natinality 5. Marital Status Married/ Unmarried 6. N. f Children 7. Crrespndence 8. Permanent Address with Address with City, Pin Cde, and State City, Pin Cde, and State 9. PWD Yes/ N 0. Disability Type. Categry SC/ ST/ OBC/ GENERAL. Bld Grup 3. ID 4. Mbile N. 5. ID Prf Type Aadhar/ Vter Id/ Pan Card/ 6. ID Prf N. Driving License
2 AREA OF SPECIALIZATION First Preference Secnd Preference IMPORTANT ELIGIBILITY CRITERIA DETAILS (Please chse any ne criteria between A r B) A CAT/ GATE/ GMAT/ GRE/ JRF Criteria Registratin N. Percentile Scre Date B One/ Tw/ Three years full-time class rm based PGDM frm any IIM/ WMP f IIM Lucknw IIM/ Prgramme Registratin N. Year f Passing Max. Marks/ Marks/ scred ACADEMIC PERFORMANCE DETAILS (Enter details f public exams class x nwards) Name f Name f Mnth & Year Subjects/ Max. Marks/ % age Divisin Curse/ Bard/ f Examinatin Specializatin Marks/ f btained Degree University/ Mnth Year btained Marks/ (if any) Institute btained X XII Bachelr Master Prfessinal Any Other ACCOUNT FOR BREAK, IF ANY
3 WORK EXPERIENCE DETAILS (Please mentin full-time jbs nly Name f Designatin Reprting Nature Perid Ttal Mnthly Organizatin t f Frm T Experience Salary Designatin Duties in mnths (Rs.) Ttal Wrk Experience as n 3 st May, 09 AWARDS/ MEDALS/ PRIZES/ SCHOLARSHIPS/ CERTIFICATES/ HONORS DETAILS Sr. N. Name f the Award Awarding Institute Year MAJOR EXTRA-CURRICULAR ACTIVITIES/ HOBBIES DETAILS Sr. Activity Yur Rle Year Ttal Awards/ Remarks N. Frm T Prizes/ Hnurs (if any) 3
4 ANNEXURE (Write a 300 wrds annexure fr each f the fllwing and attach as separate sheets). Describe yur career gals and the reasns fr yur interest in the Fellwship Prgramme. (In abut 300 wrds).. Have yu dne any research prject/ experiment/ field wrk as a part f yur master s degree? Please write a brief summary f ne such wrk in 300 wrds. This is nt mandatry. 3. Write a research prpsal describing yur initial idea abut the research that yu prpse t cnduct at IIML. (In abut 300 wrds). PAYMENT DETAILS FPM Registratin N. (Fr dwnladed frms, t be filled by the FPM Office) NEFT/ RTGS Reference N. NEFT/ RTGS Date Name f Bank Branch IFSC Cde Accunt Number Amunt (INR) DECLARATION I, hereby, certify that the particulars given by me in this frm, are true t the best f my knwledge and belief. I knw that at any time, if the infrmatin furnished by me is fund incrrect, my candidature will be cancelled immediately. Place ( ) Date Signature f Applicant 4
5 ANNEXURES (SPECIFY THE NATURE OF ATTACHMENTS)
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