Documente Academic
Documente Profesional
Documente Cultură
1. Personal Data
1.1 Name:
1.2 Date of
Birth
D D M M Y Y
1.3 Sex
2. Qualifying Examination: C A T / G A T E / G M A T / G R E / J R F / P G D M / O t h e r
(Please tick the right one and enclose the copy of mark sheet / scorecard or Grade sheet)
Year
CAT
of Appearance)
Overall
Section 1
GMAT
GRE (Gen/
Advanced)
Section 2
JRF of UGC/
CSIR
Section 3
GATE
Section 4
(if available)
Score
Percentile
*Attach score card/certificates
2.4 Nationality (If not Indian Resident or NRI, mention country name)
Indian
NRI
PIO
Other Foreign
2.5 Addresses:
(a) Mailing:
Pin
0 0 0 0 0 0
Pin
0 0 0 0 0 0
(b) Permanent:
3. Family Details
Fathers Name/ Spouses Name (if married):________________________________________________
Occupation: __________________________________________________________________________
Phone No. : ____________________________________ Mobile No: ___________________________
4. Academic Performance
4.1 Education
Stage
Title of
Qualificati
-on
Subjects/
Specialization
Max.
Marks/
CGPA
for the
Exam.
% of
Marks/
CGPA
Obtained
Class/Div.
Obtained
(if any)
th
SSE (10 )
HSSE
(10+2)
Bachelors
Degree
Masters
Degree
Professinal
Degree
(MBA/LLB/
CA/ICWA
etc.)
Any other
4.2 Please account for break in your academic career, if any: ________________________________
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4.3. Awards/Medals/Prizes/Scholarships/Certificates/Honors, etc.
(Mention only top three and those related to Academic/ Professional Activities)
No.
Awarding Institution
1
2
3
5. Total work experience in full-time jobs:__________ Years _______________ Months.
Year
5.1 Work Experience: From most recent to backward (Please mention full-time jobs only)*
Designation Reporting to
No.
Name of
Nature
Period
organization
(Designation)
of
From To
Duties
Total
Exp. in
months
Monthly
Salary
in Rs.
3
*(Add sheets if required)
6. Extra-Curricular Activities/Hobbies* (Please mention only top three)
Activity
No.
Your Role
Year
From
To
Total
Awards/Prizes/Honors, Remarks
if any
3
*(Add sheets if required)
7.
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9.
Proposed research work: (Please write about your possible idea that could be taken up for the
doctoral research by you. Please write in 150 words only).
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10. Area of Specialization (Select only two and give your order of preference (I or II))
S. No.
Area
1
2
3
4
5
6
7
8
Business Environment
Financial Management
General Management
Human Resources Management
Information Technology Systems
Marketing
Operations
Strategic Management
Preference
2. Name:__________________________________
Address:__________________________________
_________________________________________
_________________________________________
_________________________________________
____________________________Pin:__________
Email: ______________ Phone:_______________
Note: Confidential referee recommendations need to be enclosed with the application in the given format.
12. Details of Demand Draft:
Name of issuing bank ___________________________________________ Place _______________________
DD No. ______________________ Amount _____________________ Date of issue _____________________
________________________________________ 3. ________________________________________
2.
________________________________________ 4. ________________________________________
14. Declaration
All the details provided by me in this application form are true to the best of my knowledge and belief. I
will produce the original certificates on demand at any stage of the programme.
Place:_________________
Date:__________________
Last date for receiving the completed application forms at IIM Rohtak is January 25, 2013
Please mail the filled in application form to
Officer-in-charge, FPM
Indian Institute of Management Rohtak
MDU Campus, Rohtak, Haryana 124 001
FOR OFFICE USE ONLY
Areas Applied
Qualifying Test
E-mail
Area Code
:
:
SUPPORTING DOCUMENT
A. Official Transcript:
Please provide official transcripts of records and/or mark sheets (or attested copies of the
same) in support of your academic qualifications. Attestation may be done by a College or
University authorities, regular faculty of any IIM, or any Gazetted Officer whose
designation should be given. The key to the letter grade system should be included
wherever necessary.
B. Copy of the Score Card/Certificate of CAT, GMAT, GRE (General/Advanced), UGC/CSIR
JRF or GATE.
C. Writing & Research:
Please enclose with this application any published or unpublished research work which you
might have completed. You may give abstracts or summaries if the entire document cannot
be sent.
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FIRST
MIDDLE
LAST
_______________________________________________
1. I have known the applicant for __________ years and ____________ months.
2. He/she has been (please check most appropriate answer):
A student in my course(s) ________
A personal friend or acquaintance ________
My advisee ________
Other (please specify) _____________
3. Compared with a typical group of students/persons I have encountered at my institution/in my contact, I would
rank him/her as indicated below (please tick as appropriate):
CATEGORY
EXCELLENT
Top 5%
VERY GOOD
Next 10%
GOOD
Next 20%
FAIR
Next 25%
POOR
Bottom 40%
NO BASIS FOR
JUDGEMENT
Academic Strength
Motivation
Teaching Potential
Research Potential
Communication
Ability
Writing Ability
Overall Rating
4. Please write briefly about the strengths of the candidate:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
5. Please write briefly about the weaknesses of the candidate:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
6. Comments on the suitability of the candidate to a doctoral Programme (please use separate sheet, if desired):
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Your name: ____________________________
Signature:_________________________________________
Designation: ___________________________
Institute affiliation:__________________________________
Address:
__________________________________________________________________________________
_____________________________________________________________________Pin_____________________
Email:_________________________________
Phone:____________________________
FIRST
MIDDLE
LAST
_______________________________________________
1. I have known the applicant for __________ years and ____________ months.
2. He/she has been (please check most appropriate answer):
A student in my course(s) ________
A personal friend or acquaintance ________
My advisee ________
Other (please specify) _____________
3. Compared with a typical group of students/persons I have encountered at my institution/in my contact, I would
rank him/her as indicated below (please tick as appropriate):
CATEGORY
EXCELLENT
Top 5%
VERY GOOD
Next 10%
GOOD
Next 20%
FAIR
Next 25%
POOR
Bottom 40%
NO BASIS FOR
JUDGEMENT
Academic Strength
Motivation
Teaching Potential
Research Potential
Communication
Ability
Writing Ability
Overall Rating
4. Please write briefly about the strengths of the candidate:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
5. Please write briefly about the weaknesses of the candidate:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
6. Comments on the suitability of the candidate to a doctoral Programme (please use separate sheet, if desired):
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Your name: ____________________________
Signature:_________________________________________
Designation: ___________________________
Institute affiliation:__________________________________
Address:
___________________________________________________________________________________
_____________________________________________________________________Pin_____________________
Email:_________________________________
Phone:____________________________________________
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