INDIAN INSTITUTE OF MANAGEMENT INDORE Application Form

Post-Graduate Programme in Management for Executives

(PGPMX)
Commencing April 2011

A. PERSONAL DATA
Application Fee: Rs 5000/- (Rs Five Thousand Only).
Enclose Demand Draft in favour of “Indian Institute of Management Indore” payable at Indore. Please write your name with a pencil
at the back of the Demand Draft.

Demand Draft No: ____________________ Demand Draft Date: _______________ Bank:_____________________________

Name: ____________________________________________________________________________________________
(In CAPITAL letters) As recorded in your academic certificates

Sex: _________________________ Date of Birth:_________________________

Permanent Address: _________________________________________________________________________________

_________________________________________________________________________________

City: PIN Code ___________________ State _______________ Country___________

Please give your complete mailing address (valid at least till April 2011) in CAPITAL letters for intimating the final result.

Name: _____________________________________________________________________________________________
(Last name or surname) (First Name) (Middle name/initial)

Mailing Address: _____________________________________________________________________________________

_____________________________________________________________________________________

City: PIN Code ___________________ State _______________ Country___________

Tel: Residence _________________________ Tel: Office __________________________________

Mobile _________________________________ Email__________________________________________

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 B. PROFICIENCY

IF APPLYING WITH CAT SCORES:

CAT 2009/ 2010 Test Registration Number:

CAT SCORE-: (Valid Scores are CAT 2009 & CAT 2010)
Sec 1 Sec-2 Sec 3 Total
Quantitative Logic & Data interpretation Verbal

Score Percentile Score Percentile Score Percentile Score Percentile

IF APPLYING WITH GMAT SCORES:

GMAT Score Report

(GMAT score obtained between October 15, 2007 and February 01, 2011)

Test Date Scaled Scores

Month Year Verbal % Quant % Total % AWA %

score Below Score Below Score Below Score Below

IF APPLYING THROUGH BAT (BUSINESS APTITUDE TEST) TO BE CONDUCTED BY THE INDIAN INSTITUTE OF
MANAGEMENT INDORE, PLEASE TICK HERE _____________

C. ACADEMIC RECORDS

Duration Result
GPA out
Education* Exam/Degree Specialization Medium Institute City
From To % of Max
GPA

*Note: Please fill-in from your Graduate / Bachelor’s Degree onwards.

D. WORK EXPERIENCE RECORD

!"Mention ONLY full-time, paid work experience after obtaining Bachelor's degree.
!"Do not include training/project work done as an integral part of any curricular requirement. Please continue on the next page.

Employment/Professional/Entrepreneurial Work Record

Name of Industry Duration Designation Managerial Annual Functional Area

Organization Type Position Gross
From To Yes/No Salary

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 Name of Industry Duration Designation Managerial Annual Functional Area
Organization Type Position Gross
From To Yes/No Salary

Total Work Experience: ______________(In years)

Self /Career Improvement Efforts

If you have attended any self/career improvement programme please specify-:

Programme Duration Training City Benefits Gained

Attended Organization

D. CAREER PLANS
Please briefly outline your future career plans and prospects. Feel free to use additional sheets if needed.

DECLARATION
I clearly understand that if I am selected, I will be allowed to join the programme only if I satisfy all requirements of the Institute at the time of
commencement of the programme i.e. April 2011.
I certify that the particulars given by me in this interview form are true to the best of my knowledge and belief. I understand that admission
granted on the basis of false and/ or misleading information will be ipso facto null and void. I agree to abide by the decision of the institute
authorities regarding my selection/non-selection for the programme.

____________________ _______________ ____________________________

Place Date Signature of Applicant
(Name if submitting via email)

INTERVIEW DISCLAIMER
The Interview Centre for all the candidates is Mumbai, IIM-Indore reserves the right to change the interview/test centers. Documents required at the
time of Interview:
1. Candidates original CAT /GMAT Score Card
2. Original and self attested photocopies of all academic marksheets and certificates from and including Bachelor’s Degree.
3. Original and self attested photocopy of work experience certificates
4. Original and self attested copy of the passport if not a resident Indian.
5. Official ID Proof.
Note: Originals will be returned to candidates immediately after the interview.

Please read this form once again and make sure that you have completed all the items relevant to you and have fully complied with all the requirements.

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