Application Form

User Id: 7111252

CANDIDATES ARE REQUESTED TO RETAIN THE PRINTOUT OF ACKNOWLEDGEMENT PAGE FOR FUTURE REFERENCE.

Personal Details

Name of Candidate: MOHIDEEN RAHMATH FATHIMA M

Father's/Husband's/Guardian's
MOHAMED MEYAN HUSSAIN KHAN A
Name :

Mother's Name: THOULATH RABIA M

Date of Birth: 25/Sep/1994 Candidate Gender: Female

State/Union Territory of
Category: NC-OBC Tamil Nadu
Caste/Tribe:

Serial Number of caste/Tribe: 085 Caste/Tribe Name: LABBAI

Nationality: Indian Aadhar Card Number : 474172664676

Do you belong to Persons with
Disability(PwD) category as per No PwD Category:
RPwD Act 2016
Would you be requiring the Do you require wheelchair
Zoom Feature for the Test?: support at the test centre?:
Would you be using a scribe for
the Test?:

Specific query on PwD Support:

Communication Address
19C/15A JOTHI NAGAR , 4TH STREET

Address:

Country: India

State/Union Territory: TAMIL NADU Other State/Union Territory:

District: Thoothukudi Other District:

Town/City: KOVILPATTI Pin Code: 628501

Mobile Number: 9944774893 Email Address: rahmathhussain508@gmail.com

Mobile Number (Alternate) : 8072248509 Email Address (Alternate) :

Exam Centre City Preferences
Preferred City 1: Tirunelveli

Preferred City 2: Madurai

Preferred City 3: Tiruchirappalli

Preferred City 4 Chennai

Academics Details

SSC/10th Std/Equivalent Details

Aggregate marks: 90.6 Month/Year of Completion: March 2010

Total Marks Obtained : 453 Maximum Marks : 500

SSC/10th Std/Equivalent Board Tamil Nadu Board of Secondary Education (Matriculation)

Name

HSC/12th/Equivalent/Diploma Course Details

Course Type: HSC Aggregate Marks: 86
Total Marks Obtained: 1032 Maximum Marks: 1200

12th/Equivalent Board Name: Tamil Nadu Board of Higher Secondary Education

Duration of Diploma Course:

University/Board/Other Authority
Name:

Discipline: Science

Month/Year of Course
Month/Year of Completion: March 2012
Commencement:

First Bachelor Degree Details

Are you in the final year of Bachelor Degree? No

I have more than one Bachelor's Degree?

Have you completed Bachelor

Yes Total Duration of Degree: 4 Year
Degree?
Current Semester: Aggregate Marks: 75

Type of University/Institution:
State University

State/Union Territory Where Tamil Nadu

University is Situated:
First Bachelor Degree Details

University Name: Anna

Name Of College: UNIVERSITY COLLEGE OF ENGINEERING ARNI

Degree Name: BE

Discipline: Engineering/Technology

Month/Year of Course Probable Month/Year OR

September 2012 April 2016
Commencement: Month/Year of Completion:

Second Bachelor Degree Details

Are you in the final year of Bachelor Degree?

Have you completed Bachelor Total Duration of Degree:

Degree?
Current Semester: Aggregate Marks:

Type of University/Institution:

State/Union Territory Where

University is Situated:

University Name:

Name Of College:

Degree Name:

Discipline:

Month/Year of Course Probable Month/Year OR

Commencement: Month/Year of Completion:

Master Degree Details

Do you want to enter Master No
Degree Details?

Master Degree Completion Status: Duration:

Current Semester: Aggregate Marks:

State/Union Territory of
Type of University/Institution:
University:

University Name:

Name of College/Institution:

Degree Name:

Discipline:

Month/Year of Course
Month/Year of
Commencement:
Completion:
Other Professional Degree Details
Have you completed any professional degree such as CA/CS/ICWA
No
without completing Bachelor's Degree:

Professional Inter Marks: Professional Final Marks:

Month/Year of Course
Month/Year of
Commencement:
Completion:

Work Experience Details

Automobiles/Auto-ancillaries Banking/Financial Services

Durables Engineering/Industrial

Fast Moving Consumer Goods

Information Technology
(FMCG)

Pharmaceuticals/Healthcare Retail

Others
Telecommunications

Total Work Experience (In 0

months as on 31st July 2017)

Programme Details

Programme Names Interview City Selected / Not

IIM Ahmedabad PGP

(Interview City 1) Bangalore Selected

IIM Ahmedabad PGP

Hyderabad Selected
(Interview City 2)

IIM Ahmedabad EPGP

(Interview City 1
Bangalore Selected
IIM Ahmedabad EPGP
(Interview City 2 Hyderabad Selected

IIM Ahmedabad PGP-FABM Bangalore Selected

IIM Ahmedabad FPM Ahmedabad Selected

IIM Amritsar PGP Selected

Chennai
IIM Bangalore PGP Bangalore Selected

IIM Bangalore PGP EM Bangalore Selected

IIM Bangalore PGP PM Bangalore Selected

IIM Bangalore FPM Bangalore Selected

IIM Bodh Gaya PGP Bangalore Selected

IIM Calcutta PGP PGDM Bangalore Selected

IIM Calcutta FPM Kolkata Selected

IIM Indore PGP Chennai Selected

IIM Indore PGP HRM Bangalore Selected

IIM Indore EPGP Chennai Selected

IIM Indore FPM Indore Selected

IIM Jammu PGP Bangalore Selected

IIM Kashipur PGP Chennai Selected

IIM Kashipur EPGP Dehradun Selected

IIM Kashipur EFPM Kashipur Selected

IIM Kashipur FPM Kashipur Selected

IIM Kozhikode PGP Chennai Selected

IIM Kozhikode FPM Kozhikode Selected

IIM Lucknow PGP Bangalore Selected

IIM Lucknow PGP ABM Bangalore Selected

IIM Lucknow PGPSM Bangalore Selected

IIM Lucknow FPM Lucknow Selected

IIM Nagpur PGP Bangalore Selected

IIM Raipur PGP Chennai Selected

IIM Raipur PGPWE Raipur Selected

IIM Raipur EFPM Raipur Selected

IIM Raipur FPM Raipur Selected

IIM Ranchi PGDM Chennai Selected

Bangalore Selected
IIM Ranchi PGDHRM

IIM Ranchi FPM Ranchi Selected

IIM Rohtak PGP Chennai Selected

IIM Rohtak EPGP Chennai Selected

IIM Rohtak EPGPX Selected

Chennai

IIM Rohtak FPM Rohtak Selected

IIM Sambalpur PGP Chennai Selected

RGIIM Shillong PGP Bangalore Selected

RGIIM Shillong PGPEX To be decided Later Selected

RGIIM Shillong FPM Shillong Selected

IIM Sirmaur PGP Bangalore Selected

IIM Tiruchirappalli PGP Chennai Selected

IIM Tiruchirappalli PGPBM Chennai Selected

IIM Tiruchirappalli FPM Trichy Selected

IIM Udaipur PGP Chennai Selected

IIM Udaipur FPM Udaipur Selected

IIM Visakhapatnam PGP Bangalore Selected

Payment Details

Payment Mode Amount Payment Status Payment Transaction Number Order ID

online 1800.00 S JCRP5639699128 711125220170906133050702

DECLARATION

I have previewed the Application Form by clicking on the Preview Application Button and confirm that all the data reflecting in the Preview are
correct. I hereby certify that the information given by me in this Application Form is true to the best my knowledge. I certify that I fulfill the
CAT 2017 eligibility criteria and undertake to produce original documents whenever necessary and I will not demand any reschedule of exam. I
agree to abide by the declaration of the authorities regarding the eligibility of my application and understand that any misrepresentation or
omission of facts in my application may justify cancellation of my CAT 2017 application & scores. I understand that all disputes will be subject
to the territorial jurisdiction of city of Lucknow only.
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