1st Yr. TFR No.

:______________ Date :___________________

2nd Yr. TFR No. :______________ Date :___________________
(For office use)

No.
Photograph
Deccan Educations Society’s
Institute of Management Development & Research
(Founders : Padmashree Dr. R.T.Doshi, M.Com, LL.B, Ph.D.and Shree Sumatilal M. Shah )
D.E.Society Campus, Deccan Gymkhana, Pune 411 004.

Application for admission to __PGDM___________________________of _____________Session.

Please read the instructions printed at the end of this form before filling the form:

IMDR Reg No. CAT Registration No.

(For office use)
_________________________________________________________________________________
PERSONAL DATA

1. Name in full_________________________________________________________
(In Block letters) (as recorded in your academic certificates)
2. Whether member of the Scheduled Caste etc.
SC ST NT VJNT OBC OPEN

(Please tick & enclose certicicate)

3. Gender Male Female
(Please tick)
4. Marital Status Single/ Married (Please tick)
5. Place of Birth : Village/Town______________________________State:________________

6. Date of Birth: Date_________________Month____________Year_________________

7. Age as on June 30 : Years_____________ Month(s)___________________

8. Mailing Address :_____________________________________________________________

(In Block letters) ________________________________________________________________

Pin Phone
________________
9. Permanent Address :___________________________________________________________
(In Block letters) ________________________________________________________________

Pin Phone
________________

10. Person to be contacted in case of emergency: ________________________________________

(Name & address) _______________________________________________________________

Pin Phone
________________
11.Education and Occupation of Parents
 Education Occupation Position(if employed)
Father
Mother

B. WORK EXPERIENCE

Start with the present and earlier two employees. Do not include training/project work done as an integral part of curriculum.)
Organisation Designation Duration Monthly Reason for Leaving
From To Remuneration Rs.

Enclose copies of experience Certificates from the organization.

Total work experience as on 31st July _________
(see instruction no.2 on the last page)
C. EDUCATIONAL QUALIFICATIONS

a) Enclose attested copies of marksheets of graduation level and above.

b) Whether letter grades/point grades are used, their percentage equivalents should be given. A certificate
from Registrar/Principal/Head of the Department explaining the method of conversion should be
attached.
c) Fill information only if it is a Board/Council/University Examination.
Whether completed Bachelor’s Degree/Diploma? YES NO
If yes, indicate the month and year of completion of the examination.
(enclose certificate) Month_______Year_____
If No, whether you would complete the examination and all other
Requirements for obtaining the Degree /Diploma before July 31, YES NO
(see instruction no.2 on the last page)

Level Board/University Year of Maximum Marks % of

Passing Marks Obtained Marks
10th Standard
12th Standard

Bachelor of Special subject at final year

Arts Commerce Science Engg. Other ______________________
Semester Board/University Year of Maximum Marks % of
System/Yearly Passing Marks Obtained Marks
Exam.
I
II
III
IV
V
VI
VII
VIII

Master of Special subject

Arts Commerce Science Engg. Other ________________

Year
I
II

D. OTHER RELEVANT INFORMATION

1. Rate your academic performance uptil now : ______poor/ _____fair/ _____good _______outstanding
2. Write about yourself as a person.
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________

3.Extra-curricular activities (give details of sports, games, hobbies and other activities you consider worth
mentioning, include awards received, position held in different associations, etc.)
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________

Rate your performance in extra-curricular actrivities:_____poor/ _____fair/ _____good/ _____outstanding

4. State your career goals five years from now.

______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
 E. DECLARATION

I declare that the information given by me in this application is true to the best of my knowledge. I agree
to comply with the rules of the Institute, if admitted.

I have carefully noted the rules, regulations etc. (as given in the Prospectus received alongwith this form)
which I am required to follow. I have also noted that the Director’s decision in all respects will be final and
binding. I am aware that tuition fee paid is not refunded under any circumstances and I shall not ask for its
refund.

I hereby submit to the disciplinary jurisdiction of the authorities of the Institute and shall observe and abide
by the rules made by the Head of the Institute, from time to time.

Place ___________
_____________________
Date____________ Signature of the applicant

Enclosures

1.__ ____________________________________4._______________________________________

2._____________________________________ 5._______________________________________

3._____________________________________ 6._______________________________________

INSTRUCTIONS

1. If you are yet to complete your Bachelor’s degree examination, or any other qualifying examination,
enclose certificate from the Head of your Institute /Department stating that you would be completing
examination and all other requirements for obtaining the Degree /Diploma by July .

2. Please note that wherever year is required, it should be the year of commencement of the course.(e.g. If
you have applied for the PGDM 2011-13 course, mention age as on June 30th, 2011)

3. Attestation of marksheets may be done by the Principal/Registrar/Head of your Department/College/

University /Institute, an MP/MLA or Gazetted Officer.

4. The decision of the Director in all matters relating to admission will be final and binding.

5. Admission to the Programme on the basis of incomplete and /or false information will stand
automatically cancelled.

6. Incomplete application may not be considered for the purpose of selecton. Applicants are, therefore,
advised to ensure in their own interest that all relevant documents are enclosed with the completed
application form. Candidates are also advised not to leave any column blank.

7. Four address coupons are attached to this form. Please use them to write the address on which you
want to receive all correspondence relating to admission. Please write the identical address slips
provided.

8. If downloaded from the website, kindly refer to the Admission Notice for the Demand Draft which
 must accompany the completed application.
………………..

Name: ____________________________ Name : _____________________________

Address : __________________________ Address : ___________________________
__________________________________ ___________________________________

__________________Pin ___________________ Pin

Phone: ____________Fax:____________ Phone: ____________Fax:____________

E-mail:____________________________ E-mail:____________________________

Name: ____________________________ Name : _____________________________

Address : __________________________ Address : ___________________________
__________________________________ ___________________________________

________________Pin ___________________ Pin

Phone: ____________Fax:____________ Phone: ____________Fax:____________

E-mail:____________________________ E-mail:____________________________