Indian Institute of Information Technology, Allahabad

(A University Established under Sec. 3 of UGC Act, 1956 vide Notification No. F.9-4/99-U.3 Dated 4/8/2000 of the Govt. of India)
Deoghat Jhalwa, Allahabad – 211012 (U.P.) India
Ph: +91-532-2922032/33, Fax: +91-532-2430006, 2431689, 2922081Web:www.iiita.ac.in; E-mail: contact@iiita.ac.in
Admission Notice for MBA-IT & MS-CLIS Programs: 2011 – 2012
A Centre of Excellence in Information Technology established by Ministry of HRD, Govt. of India, having
all the state of the art infrastructure in place invites for admission:
No. of Seats available Last date of
Sale of
issuing (in person)
Application Entrance
S. Name of Qualifying Degrees/ & receiving
Form-cum Exam
No. Program SC ST OBC Gen Total* Examination completed
Information Dates
application forms
Brochure
at IIIT-A counter
Graduates from any
M.B.A. in 23rd -24th
discipline with valid 16th Nov.
01. Information 11 06 21 38 76 24th March 2011 April
CAT score (GMAT 2010
Technology 2011
score for FN/NRI’s)
MS (Cyber
BE/B.Tech./Post 26th -27th
Law & 16th Nov.
02. 11 06 21 38 76 Graduates/Bachelor 21st Jan. 2011 February
Information 2010
in Law 2011
Security)
IIIT-A uses CAT score for short-listing the candidate for our MBA-IT(2Yrs.) full time Post Graduate Program in Management.
IIMs have no role either in the selection process or in conduct of the program.
• NRI/Sponsored/FN/SAARC (supernumerary seats) 5*
• Seats for Physically Handicapped (PH) candidate: 3% of total with horizontal reservation.
• All Reservations for various categories as per GoI guidelines apply. In case application of some other reservation
has to be brought in force and likewise seats would be adjusted and it may be incorporated.
• Candidates appearing in Qualifying Degree Examinations may also apply. [If final result is likely to be declared
by 14th July 2011]
• Candidate interested for more than one program needs to fill in a separate form.
The forms may be obtained both in person or can be downloaded from the website www.iiita.ac.in . The cost of
application form is Rs. 1200/- (Rs.600/- for SC/ST/OBC candidates) to be paid in cash or through DD of MICR type
from any nationalized bank drawn in favour of ‘IIIT-Allahabad’ payable at Allahabad.
IIIT-A Counters to collect the Application Form
IIIT-A Jhalwa Campus Deoghat, Jhalwa Allahabad -211012, Phone: +91-532-2922032/33
Nehru Science Centre Allahabad, Kamala Nehru Road, Allahabad- 211002,Phone:+91-532-2461377
IIIT-A Delhi Guest House, 564, Sachin Nag Block, Khelghoan, New Delhi, Phone: +91-11-26494595
Rajiv Gandhi Institute of Information Technology Teekarmafi, Amethi – 227120, Phone: +91-5368-273220/222
Professor In-charge Exam Cell
 Indian Institute of Information Technology, Allahabad
(A University Established under Sec. 3 of UGC Act, 1956 vide Notification No. F.9-4/99-U.3 Dated 4/8/2000 of the Govt. of India)
(A Centre of Excellence in Information Technology, Established by Govt. of India)
Deoghat, Jhalwa, Allahabad -211 012 (U.P.), INDIA
Ph. +91-532-2922032/33; Fax. 2431689/ 2430006/ 2922081; Web: www.iiita.ac.in; E-mail: contact@iiita.ac.in

APPLICATION FORM FOR ADMISSION TO MBA-IT / MS -CLIS PROGRAM – 2011

(For filling this application form see instructions overleaf)
Program for which Admission is sought: (Please Tick only one)
I. MBA in Information Technology (MBA-IT)
Paste your
II. Master of Science in Cyber Law & Information Security (MS-CLIS) Self attested
photograph
Either TYPE or filled by hand writing using Capital Letters
here
CAT Registration No*. (MBA-IT Candidates Only)

CAT Center Code * (MBA-IT Candidates Only)

* As in the CAT Admit Card

1. FULL NAME: ______________________________________________

2. DATE OF BIRTH: __________________ 3. PLACE OF BIRTH: ___________ 4. SEX: MALE/FEMALE

5. MARITAL STATUS: ______________________ 6. NATIONALITY: _______________________

7. FATHER’S NAME: _________________________________ MOTHER’S NAME: ______________________________

8. ADDRESS FOR CORRESPONDENCE: _______________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

______________________STATE: ____________________ PIN CODE: _____________________

9. Please provide :
Phone No. : (_______)___________Fax No. : (_________)_______________ E-mail address : _______________

10. Details of Demand Draft (For Downloaded or Xeroxed Forms only)

Pl. make sure that Demand Drafts issued are ‘MICR’ TYPE only
a) Amount Rs. ………………….. No. ………………………. Dated………………………

b) Bank & Branch issued ……………………………………………………………………

11. Category GE SC ST OBC SN NR PH (Please TICK which are applicable)

12. A. CAT exam details (*) / GMAT Score details for NRI / Foreign Nationals Program/ NOT for Sponsored candidates

(APPLICABLE TO APPLICANTS FOR MBA –IT PROGRAM ONLY)

Exam Name Percentile Score Exam Year
CAT / GMAT

B. Qualifying Degree (*) already obtained or in progress

University/ Discipline Degree Exam Date Final results Overall % or

Institute expected by Grade Average (if
degree completed

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 BACK PAGE OF MBA -IT / MS-CLIS APPLICATION FORM

C. Working Experience (**) (Latest three only)

Company Name with Full Reporting Office / Designation Experience

Address, E-mail & Contact No. Employer, along with (Date From - To)
Phone No. & Email ID

13. Declaration by the applicant:

Certified that all information provided by me in this form is correct to the best of my knowledge and belief. I understand that
any willful misrepresentation of facts will result in my admission being cancelled / dismissal from the Institute. If admitted, I
shall abide by all the rules and regulations of the Institute.

Date : __________________ Signature of Candidate _______________________________________

Place : __________________________

14. Declaration by Parent/ Guardian (Not to be filled by sponsored candidates)

In the event of Mr./Ms. _______________________________ son/ daughter/ ward being admitted, I hereby give an
undertaking to pay regularly all admissible dues to the Institute and Hostel till the completion of his/ her studies. I also
undertake the responsibility for his/ her good conduct.

Date : __________________ Signature of Parent/Guardian____________________________________

Place : __________________________

(*) Attach attested copies of certificates, marksheet etc. See checklist overleaf for certificates required.
(**) A candidate presently working (including those on projects) must provide a “No Objection/Relieving certificate” from the
employer.
• Recommendation letter from the company in their company letter head & seal are required.
• Summer training & placement for sponsored category will not be arranged by the institute.
($) Photocopies of this form or copies downloaded from IIIT-Allahabad website (http://www.iiita.ac.in) are acceptable; however,
photocopies or downloaded forms must accompany the required Demand Draft of Rs.1200/ Rs.600, as the case may be, drawn in
favour of IIIT-Allahabad and payable at Allahabad.

INSTRUCTIONS FOR FILLING THIS FORM

1. Either TYPE or filled by hand using capital letters or in clear handwriting the entries on the form neatly.
2. All items marked with an asterisk (*) require you to submit an attested copy of some document. PLEASE DO NOT SEND
ORIGINALS. Documents for which attested copies are required are given in the checklist. Please tick off the items in this
checklist you are attaching to this form.
3. The application fee of Rs.1200/- for candidates in general category (Rs.600/- for SC/ST/OBC candidates) must be paid through
demand draft payable to “IIIT-Allahabad” at Allahabad.
4. Item 11: Category
SC* : Scheduled Caste; ST* : Scheduled Tribe; OBC* : Other Backward Cast; GN : General, NR* : Non Resident Indian; PH* :
Physically Handicapped; SN* : Sponsored
Checklist (Please Circle the enclosed documents). Send Only Attested Copies (DD & Sponsor’s certificate in Original please.)

1. Date of birth (DOB) certificate or High School (Class Ten) Certificate with DOB (Required for all candidates)
2. SC/ST/PH/ OBC/ DPD Certificate if applicable (Item 11)
3. CAT / GMAT score card (Item 12 A)
4. Copies of mark/grade sheets (Item 12 B)
5. No Objection/relieving Certificate from employer (for sponsored candidates only)
6. Sponsorship Certificate/Recommendation letter from the company in their company letter head & seal
7. In case of downloaded filled in application form, the form accompany the DD of MICR type for Rs.1200/- or Rs.600/- as
applicable, without which it shall be summarily rejected.
8. Three letters of reference (for all Non GATE qualified applicants)
9. Equivalence Certificate in case Grades are awarded by the Qualifying Degree granting Institution.

IMPORTANT DATES
Date of Entrance Test & Interview (at IIIT-Allahabad only) for screened in applicants in
•
rd th
MBA-IT 23 -24 APRIL, 2011
• MS-CLIS th th
26 -27 FEBRUARY 2011

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 SPONSORSHIP CERTIFICATE / RECOMMENDATION
(for sponsored candidates only)

(This should be typed on a letterhead of the Sponsoring Organization and enclosed with application for admission).

To,
The Director,
Indian Institute of Information Technology Allahabad
Deoghat, Jhalwa,
Allahabad -211 012 (U.P.), INDIA

Sub : Sponsoring of our employee for MBA (IT) / MSCLIS Program at IIIT-Allahabad.

Dear Sir,

We hereby Sponsor the candidature of Mr. / Ms. ___________________________________________, an

employee in our organization, for joining his/ her MBA-IT / MS-CLIS Program at your Institute as a full-time
candidate.
He / She have been employee of our organization for ____________________years.
We shall bear the total expenses of his/ her studies. We shall fully relieve him/ her of his/ her duties in the
organization during the entire period of the MBA-IT / MS-CLIS Program to enable him/ her to devote full time
to the studies. The organization would also take care of the summer training and placement of the above
candidate.

We also certify that his/ her conduct at our organization has been good.

Signature and Seal of

The Sponsoring Authority
Date:
Phone / Mobile No…………………….
E-mail ID……………………………….

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 Indian Institute of Information Technology, Allahabad
(A University)
(A Centre of Excellence in Information Technology, Established by Govt. of India)
Deoghat, Jhalwa, Allahabad -211 012 (U.P.), INDIA
Ph. +91-532-2922032/33; Fax. 2431689/ 2430006/2922081; Web: www.iiita.ac.in; E-mail: contact@iiita.ac.in

LETTER OF REFERENCE CONFIDENTIAL

Note to the Candidate:
Please give this form to a referee who can help us with his assessment of your academic potential for pursuing ………... in
your desired field of study. The referee may be requested to mail it directly to us (ar.ex@iiita.ac.in) after filling it. Please
however fill in your name & desired program of study, before handing this form over to the referee;

Name of the Applicant (Surname First)

Program to which admission is sought

1) MBA in Information Technology (MBA-IT)

2) Master of Science in Cyber Law & Information Security (MS-CLIS)
Note for Referee
To help us in the appraisal of the candidate’s case for admission to a Post graduate program at IIIT-Allahabad, you are
requested to fill in the following information to the best of your knowledge. This information will be treated as strictly
confidential.

1. I have known the applicant for past ___________________ years.

2. My knowledge of this student is based on (please tick):

Having him/ her in one or more courses.

Knowing him/ her personally

Supervision of his/ her thesis/ project

Inquiry and discussion with my colleagues

Interaction with him/ her in connection with his/ her conference Paper
Presentation/ Project/ other Technical Discussions
3. Performance in my Courses:

Course Title No. of Students Grade Remarks

4. The candidate ranks approximately ___________ in a class of about __________ students.

5. A note on general observations

about the candidate including
his/ her professional achievement,
etc., if any

(Please attach separate sheet, if required.)

4
6. My rating of the candidate in Following trials (please tick):

Excellent Good Fair Unable to Judge

Analytical Ability

Experimental Skills
Motivation
Written and Oral
Expression

Responsibility & Initiative

Teaching Ability

Sincerity & Dedication

7. To summarize, I would like to say that the applicant (please tick) :

is likely to become a brilliant scholar or an outstanding leader in his/ her chosen field.

is likely to do very well in the Post Graduate program

is likely to perform satisfactorily.

is not a good prospect.

8. My recommendation:

I recommend him/ her enthusiastically

I recommend him/ her

I do not recommend him/ her

Name of the Referee ________________________________ Signature ________________________________

Designation/ Position _______________________________ Date ____________________________________

(with Name & Address
of the Organization) ________________________________________________________________________

Address ________________________________________________________________________

________________________________________________________________________

Pin Code________________________________________Fax : ____________________

Telephone No. (with STD code) _______________ (Office)______________(Residence)_____________(Cell)

Professional qualification of the Referee _________________________________________________________

Please send this form directly to:

The Asst. Registrar (Exam)
Indian Institute of Information Technology Allahabad
Deoghat, Jhalwa, Allahabad -211 012 (U.P.), INDIA
Email: ar.ex@iiita.ac.in

Note: Kindly write “Application for MBA-IT” or “Application for MS-CLIS” on the envelope as applicable.

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 IIIT-ALLAHABAD – 2011

MEDICAL EXAMINATION REPORT

(To be issued by a Registered Medical Practitioner only)

GENERAL EXPECTATIONS

Candidates will have good general physique with

a) Chest Measurement should not be less than 70 cm, with satisfactory limit of expansion and contraction.
b) Vision should be normal. In case of defective vision, it should be corrected to 6/9 in both eyes or 6/6 in
the better eye.
c) Hearing should be normal. Defective hearing should be corrected.
d) Heart and lungs should not have any abnormality and there should be no history of mental disease or
epileptic fits.

PERSONAL HISTORY

1. Name …………………………………………………………………………………………………

2. Parent/ Guardian’s Name:

(a) Father’s Name …………………………………………………………………………………….
(b) Mother’s Name ………………………………………………………………………………….

3. Age: …………………………………………… Years …………….. Months………………………

4. Sex:……………………………………..

5. Identification Marks on the Body: ……………………………………………………………………

(This can be a mole, scar or birthmark.)

6. Major illness / operation: ……………………………………………………………………………

(Specify nature of illness / operation.)

MEDICAL CERTIFICATE

(The following are to be filled by the Medical Officer conducting the medical examination.)

1. Height :………………………cm. 2. Weight:……………………………kg.

3. Past History: 4. Chest :

a) Mental Disease ….............................. a) Inspiration…………………….cm.

b) Epileptic Fit ………………………... b) Expiration……………………..cm.

5. Blood Group ……………………………….. 6. Hearing:……………………………

7. Vision with or without glasses :

a) Right eye : ……………………….. c) Colour Blindness :……………………….

b) Left eye : ………………………… d) Uniocular Vision :……………………….

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8. Respiratory system:………………………… 9. Nervous system:…………………………

10. Heart: 11. Abdomen:

a) Sounds:………………………….. a) Liver: ………………………….

b) Murmur:…………………………. b) Spleen :…………………………

12. a) Hernia:…………………………………… b) Hydrocele :……………………………………

13. Any other defects :……………………………………………………………………………………

Certified that ……………………………………………………………………………………………….

son/daughter of ………………………………………………………………………………………………

a) Fulfills the prescribed standard of physical fitness and is FIT for admission to MBA-IT / MS-CLIS
Programs offered by IIIT-A.
b) does not fulfill the prescribed standard of physical fitness and is unfit / temporarily unfit to admission
due to following defects :

___________________________ ____________________________
Signature of the Medical Officer Signature of the Candidate

Full Name :………………………………………….

MCI Registration No. ………………………………

Official Seal :……………………………………….

Date :…………………………………………………