BIMTECHBIRLA INSTITUTEOF MANAGEMENT TECHNOLOGYExC<!n.""" with V.lu".

APPLICATION FORM FOR ADMISSION-2014PGDM PROGRAMMES FOR GREATER NaiDA CAMPUS

(Important Note: - Use Ball Point Pen to fill the application in CAPITAL LETTERS)

Application Form No. (For Office use only) .

Applicants last name .

PASTE HEREFIRMLY YOUR

RECENT COLORPHOTOGRAPH

Applicants first name .

Applicants middle name .

Date of Birth (dd/mm/yyyy) .

Category DSC 0 ST 0 OBC (Non-Creamy) 0 General

! Is Physically Handicapped 0 Yes 0 No Is Economicaliy Backward DYes D No

Gender 0Male 0Female Nationality Domicile State .

Address Line 1 .

Address Line 2 .

Address Line 3 : City .

,Country.............................. State . Pin Code: .

Telephone STD Code Telephone Number Mobile No .

E-mail id .......................................................•... Alternate E-mail id .

Father's Name................ Mother's Name .

Father's Occupation Mother's Occupation .

Total Annual Income (of Both the Parents) .

Work Experience from to Work Exp. in Months .

Name of the Organization Work Experience Sector .

Company turnover (Min. Rs. 50 Crore)................................. Designation .

Eligible Role 0 Executive 0 Supervisory 0 Managerial D Annual Salary Package (Min. Rs. 1.8 Lakh) .

SSC Board .

SSC Percentage (all subjects) SSC Mode (eg. Regular/PrivatelDistance) .

HSC Board HSC Discipline (eg.-Science/Commerce/Arts) .

HSC Percentage (all subjects) HSC Mode (eg. Regular/PrivatelDistance) .

Birla Institute of Management Technology, Plot No.5, Knowledge Park II, Greater Noida, 201 306, IndiaTel: +91-120-2323001-10, Toll Free NO.-180018001111, Mobile:-9718444466

Website: www.bimtech.ac.in. Email: admission.gueries@bimtech.ac.inPage 1 of 3

~ BIMTECH• BIRLA INSTITUTE

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Whether Bachelors Degree Completed DAre there any paper(s) uncleared / to be repeated

Yes D No Year of Passing .

DYes D No

Bachelors Degree Percentage (If Completed) (If Not Completed - Aggregate till last year) .

Bachelors Degree Name (e.g. BA, B,Sc, B.Com. etc.) .

Bachelors Degree Mode (eg. RegularlDistance Learning/Correspondence) .

Bachelors Degree Type of University (eg. Central/State/Deemed/NITIIiTlAny Other) .

Bachelors Degree University State (eg. UP/MP/KeralalWest Bengal etc) .

Bachelors Degree University Name .

Bachelors Degree Institute/College Name .

1Do you wish to apply for BIMTECH scholarship? DYes D No

TEST DETAILS REGISTRATION NO PERCENTILE.CAT-2013

XAT-2014

MAT- (Sep/Dec-2013 or Feb-2014)

CMAT- (Sep-2013/Feb-2014)

GMAT - (2013-14)

Note: (1) For CMA T Candidates only to enter their CMAT Score (out of 400)(2) For eligibility criteria, please visit http://bimtech.ac.in/admissions/fee-structure/

Note: You can tick C-J) any two candidate categories in order of preference

Preference-1 Preference-2S.No. Candidate Category

(tick only one) (tick only one)

1 Merit

2 Corporate Sponsored

3 NRI Sponsored

4 NRI

5 International Student

Birla Institute of Management Technology, Plot No.5, Knowledge Park II, Greater Noida, 201 306, IndiaTel: +91-120-2323001-10, Toll Free NO.-180018001111, Mobile:-9718444466

Website: www.bimtech.ac.in.Ernail:admission.queries@bimtech.ac.inPage 2 of 3

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~ BIMTECH• BIRLA INSTITUTE

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Note: You can ..tick ('-.1) any two programs preferences in order of preference

Preference-1 Preference-2S.No. Program Preference

(tick only one) (tick only one)

1 PGDM

2 PGDM (International Business)

3 PGDM (Insurance Business Management)

4 PGDM (Retail Management)

5 PGDM (Sustainable Development Practices)

Note: You can tick (,J) anyone GO/PI preference -,. .~

City for attending GO/PIPreference

D Bhubaneswar D Greater Noida

How did you come to know about BIMTECH? .(e.g. News Paper AdvertisementlEducational PortallCoaching Institute/Alumni/StudentlTV Commercial etc )

r Demand Draft Details: DO No DO Date: .

Drawn on Bank: Branch: .

Demand Draft for Rs. 1050/- drawn in favour of "BIRLA INSTITUTE OF MANAGEMENT TECHNOLOGY", payable at Greater Noida

INoidalNew Delhi. (Only accepted with the application form downloaded from www.bimtech.ac.in)

DECLARATION BY THE CANDIDATE

I certify that I satisfy the eligibility requirements of the programmes I have applied for and have furnished complete and correct

i information. I also undertake to abide by BIMTECH decisions on all matters regarding the application. In case of any, .discrepancy BIMTECH has full right to cancel my candidature. I undertake to produce the final graduation degree and mark

sheets latest by 31st Oct. 2014, failing which BIMTECH will be free to cancel my admission.

Place: . Signature of the Candidate: .

, Date: 1 1 .

Birla Institute of Management Technology, PlotNo. 5, Knowledge Park II, Greater Noida, 201 306, IndiaTel: +91-120-2323001-10, Toll Free NO.-180018001111, Mobile:-9718444466

Website: www.bimtech.ac.in. Email: admission.gueries@bimtech.ac.inPage 3 of 3