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Please send this Application Form along with1)Demand Draft for Rs.1,200 towards cost of IBSAT 2010 Application Material (demand draft should be drawn in favor of "IUCF A /c IBS" payable atHyderabad)2) Attested copies of X Class, XII Class and graduation markssheets (Year Wise / Semester Wise), students who are pursuing th eir final year degree haveto attach the markssheets till last semester/year to Admissions Officer, IBSAT Office, #6 -3-354/1/2, Hindi Nagar, Punjagutta, Hyderabad-500034
IBSAT 2010 ONLINE APPLICATION FORM ( DECEMBER 26, 2010)
Application No. 75 2011
Name of theApplicant (Use capital letters) MOUMITA SAMANTA
Application No. 752011
Test Center (Code) New Delhi(GeethaColony) ( 531 ) G ender Female
Indian Citizen Yes
Medium of Instruction ( English ) Y/N
Class X Yes Class XII Yes Degree Yes
Date of Birth(DD/MM/YEAR) 20 01 91
Academic Record
Class X Agg. Marks (%) Year of Passing 70 2006
Class XII 8 6.7 200 8
Qualification (Code) Mode of Study Duration of Course (No. of
Yrs) Status Agg. Marks (%) Year of
Passing
Bachelor'sDegree
BB A/ BB M/ BB S ( 23 )
DistanceLearning 3 Years F inal Year 59 2011
P .G Qualification -
P rofessionalQualification -
Work Experience ason May 31, 2011: Nil
Address(full postal address)
9 / 8 0 8 PREM GALI- 2 EGANDHI NAGARDELHI
City New Delhi S tate (Code) Delhi ( 06 )
P in code 110031 Mobile 9873428338 Telephone Number 9 8 7342 8 33 8
Name ( Write your name the way it ismentioned in your S chool/Degreecertificates.)
MOUMITA SAMANTA
E-Mail Address 1 MOUMITA 3 8 9@ GMAIL. COM
E-Mail Address 2 [email protected]
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Name & Address of the College (Degree)(Use capital letters)
JAGAN NATH INSTITUTE O F MANAGEMENT SCIENCES34, LAJPAT NAGAR- IVNEW DELHI110024
Name of theUniversity (Degree)(Use capital letters)
Guru Jambheshwar University , Hissar
Executive-Level work Exeperience (if applicable)
Employer's Name & Address Period of Service Designation Area of Work
From To -- -- -- -- --
Family income(per annum) : Above Rs.5 lakhs Declaration I declare that I have read and clearly understood the disclosure and the legal aspects and the eligibility criteria for admis sion into the IBSAT I herebyagree to abide by the same. I certify that I satisfy the eligibility requirements as stated in the IBSAT 2010 Application Material/Website.I hereby declare
that the information provided by me in theOnline Application is true and correct to the best of my knowledge. I have read, un derstood and agree to therules and regulations of IBSAT. P lace: New Delhi ______________________ Date: (MM/DD/YYYY) 11 / 3 / 2010 S ignature of the Applicant
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