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Indian Institute of Information Technology Allahabad (A University Established under Sec. 3 of UGC Act, 1956 vide Notification No. F.9-4/99-U.3 Dated 4/8/2000 of the Govt. of India)

(A Centre of Excellence in Information Technology)

Devghat, Jhalwa, Allahabad -211 012 (U.P.), INDIA

Ph. 0532-2922025/2431692; Fax. 2431689/ 2430006; Web: www.iiita.ac.in; E-mail: contact@iiita.ac.in

Application form for Admission to MBA(IT) and Dual Degree MBA(IT) - Ph.D. Programme 2014 (All fields are mandatory unless otherwise marked. See instructions overleaf for filling the form)

Please mention 1 and/or 2 according to your preference for admission in the box given below:

I. MBA in Information Technology - MBA(IT)

II. Dual Degree MBA(IT)- Ph.D.Program

Either TYPE or fill by hand in CAPITAL Letters

1. FULL NAME : ______________________________________________

2. Category (Please TICK only)

3. FATHERS NAME : ______________________________ 4. Mothers Name ______________________________

5. DATE OF BIRTH : __________________ 6. Place of Birth : _________________________ 7. SEX : MALE/FEMALE

8. MARITAL STATUS : ______________________ 9. NATIONALITY : _______________________

10. ADDRESS FOR CORRESPONDENCE : _________________________________________________________________

_________________________________________________________________________________________________

______________________STATE : ____________________ PIN CODE : _____________________

11. Phone No./Mobile No :_________________Fax No. (if any) : (_____)____________

E-mail address : ______________________________Alternate E-mail address : _____________________________ (case sensitive)

(Institute is not responsible for any false contact or incomplete contact. E-Mail address should be filled neatly and clearly)

12. Details of Demand Draft (for downloaded/ photocopy/online generated forms only)

Pl. make sure that Demand Drafts issued are MICR TYPE only and payable at Allahabad in favor of IIIT-Allahabad.

a) Amount Rs. .. No. . Dated

b) Bank & Branch issued

13. A. CAT/GMAT

Registration No*.

B. Center Code * * As in the Admit Card

C. CAT exam details (*) / GMAT Score details for NRI / Foreign Nationals Program

Exam Name Percentile Score Exam Month &Year

CAT/ GMAT

14. Qualifying Degree (*) already obtained or in progress

University/

Institute

Discipline Degree Min. Pass

Marks % or

Grade Average

Overall % or

Grade Average (if

degree

completed)

Exam Date (in

case of final

year)

Final results

expected by which

year/ NA

15. Working Experience (**) (Latest three only)

Paste your

Self attested

good quality

color

photograph

here

GE SC ST OBC PH DPD SN NR FN

Community (only for OBC minority

candidates)

2

Company Name with Full

Address, E-mail & Contact No.

Reporting Office/

Employer, along with

Phone No. & Email ID

Designation Experience

(Date From To)

16. Declaration by the applicant:

Certified that all information provided by me in this form is correct to the best of my knowledge and belief. I understand that any

willful misrepresentation of facts will result in my admission being cancelled / dismissal from the Institute. If admitted, I shall abide

by all the rules and regulations of the Institute.

Date & Place: __________________________________Signature of Candidate _______________________________________

17. Declaration by Parent/ Guardian

In the event of Mr./Ms. _______________________________ son/ daughter/ ward being admitted, I hereby give an undertaking to

pay regularly all admissible dues to the Institute and Hostel till the completion of his/ her studies. I also undertake the responsibility

for his/ her good conduct. I am also aware that RAGGING is prohibited at the Institute and is treated as a cognizable offence at

IIIT-A under the Indian Penal Code & the directions of Honble Supreme Court of India and will ensure that he/she will not be involved in any ragging related activity. He/She shall maintain honour and dignity of the Institute.

Date & Place: __________________________________Signature of Parent/Guardian_________________________________

Note:

Applications are subject to screening and shortlisting.

Incomplete form in any respect will be primarily rejected.

Only Hostel & Mess Fees are refundable in case of withdrawal from admission.

(*) Attach attested copies of certificates, mark sheet, etc. see checklist overleaf for certificates required.

(**) A candidate presently working (including those on projects) must provide a No Objection/Relieving Certificate from the employer.

Recommendation letter from the company in their company letter head & seal are required. ($) Photocopies of this form or copies downloaded from IIIT-Allahabad website (http://www.iiita.ac.in) or online generated forms are

acceptable; however, photocopies or downloaded or online generated forms must accompany the Demand Draft of Rs. 1200/- for

General and OBC (Rs.600/- for SC/ST/PH candidates).

INSTRUCTIONS FOR FILLING THIS FORM

1. Either TYPE or fill in CAPITAL letters by hand. 2. All items marked with an asterisk (*) require you to submit an self attested copy of some document and not the originals.

Documents for which self attested copies are required are given in the checklist.

3. The application fee of Rs. 1200/- for General and OBC (Rs.600/- for SC/ST/PH candidates) must be paid through demand draft payable to IIIT-Allahabad at Allahabad.

4. The abbreviations of categories are as follows: SC* : Scheduled Caste; ST* : Scheduled Tribe; OBC* : Other Backward Cast; GN : General, NR* : Non Resident Indian;

PH* : Physically Handicapped; SN* : Sponsored; FN*: Foreign National (including SAARC); DPD*: Armed Forces Personnel

Killed/Disabled.

Checklist (Please circle the enclosed documents).

Send the self attested copies for below mentioned 1 to 6 and original for 7 to 9 please (without which it shall be summarily rejected).

1. Date of birth (DOB) certificate or High School (Class Ten) Certificate with DOB (Required for all candidates) 2. SC/ST/PH/OBC/DPD Certificate if applicable (Item 2) 3. CAT /GMAT score card (Item 13 C) 4. Copies of marks/grade sheets (Item 14). 5. Equivalence Certificate in case Grades are awarded by the Qualifying Degree granting Institution. 6. No Objection/Relieving Certificate from employer (for sponsored candidates only). 7. Medical Examination report. 8. Sponsorship Certificate/Recommendation letter from the company in their company letter head with seal. 9. Three letters of reference (for all GMAT qualified & sponsored applicants) 10. In case of downloaded or photocopied or online generated application form, the form should be enclosed with the DD of MICR

type for Rs.1200/- (General/OBC) or Rs.600/- (SC/ST/PH) as applicable, without which it shall be summarily rejected.

IMPORTANT DATES

Date of GD & Personal Interview (at IIIT-Allahabad only) for screened in applicants

for MBA( IT) and Dual Degree MBA(IT) - Ph.D. : 12th April 2014. ( Please visit our website for regular updates and for any entrance test schedule changes)

Please send the complete filled in application to : The Asst. Registrar (Exam), Indian Institute of Information Technology

Allahabad, Devghat, Jhalwa, Allahabad -211 012 (U.P.), INDIA.

Note: Kindly write Application for MBA(IT)/Dual Degree MBA(IT) - Ph.D. on the envelope as applicable.

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SPONSORSHIP CERTIFICATE

(for sponsored candidates only)

(This should be typed on the original letterhead of the Sponsoring Organization and enclosed with application

for admission).

To,

The Director,

Indian Institute of Information Technology Allahabad

Devghat, Jhalwa,

Allahabad -211 012 (U.P.), INDIA

Sub : Sponsoring of our employee for MBA(IT)/ Dual Degree MBA(IT)-Ph.D. Program at IIIT-

Allahabad.

Dear Sir,

We hereby Sponsor the candidature of Mr. / Ms. _____________________________________ working

as______________________________in our organization, for joining as a full time candidate for MBA(IT)/

Dual Degree MBA(IT)-Ph.D. Programme at your Institute.

He/ She have been employee of our organization for ____________________years.

We shall bear the total expenses of his/ her studies. We shall fully relieve him/ her of his/ her duties in the

organization during the entire study period of the program. The candidate would do the summer training in the

sponsor organization and will rejoin the organization after the study period gets over.

We also certify that his/ her conduct at our organization has been good.

Signature and Seal of

The Sponsoring Authority

Date:

Phone/Mobile No.. E-Mail ID..

(Note: Sponsoring authority should be DGM/GM/Honble position holders)

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Indian Institute of Information Technology Allahabad (A University Established under Sec. 3 of UGC Act, 1956 vide Notification No. F.9-4/99-U.3 Dated 4/8/2000 of the Govt. of India)

(A Centre of Excellence in Information Technology)

Devghat, Jhalwa, Allahabad -211 012 (U.P.), INDIA

Ph. 0532-2922025/2431692; Fax. 2431689/ 2430006; Web: www.iiita.ac.in; E-mail: contact@iiita.ac.in

(Applicable only for Sponsored / GMAT Applicants)

LETTER OF REFERENCE Note to the Candidate:

Please give this form to a referee who can help us with his assessment of your academic potential for pursuing ... in your desired field of study. The referee may be requested to mail it directly to us after filling it. Please however fill in your

name & desired program of study, before handing this form over to the referee;

Name of the Applicant (Surname First)

Program to which admission is sought

1) MBA(IT)

2) Dual Degree MBA(IT) - Ph.D.

Note for Referee:

To help us in the appraisal of the candidates case for admission to a Post graduate programme at IIIT-Allahabad, you are requested to fill in the following information to the best of your knowledge. This information will be treated as strictly

confidential.

1. I have known the applicant for past ___________________ years.

2. My knowledge of this student is based on (please tick):

Having him/ her in one or more courses.

Knowing him/ her personally

Supervision of his/ her thesis/ project

Inquiry and discussion with my colleagues

Interaction with him/ her in connection with his/ her conference Paper

Presentation/ Project/ other Technical Discussions

3. Performance in my Courses (in case you have taught him):

Course Title No. of Students Grade Remarks

4. The candidate ranks approximately ___________ in a class of about __________ students (in case you have

taught him).

5. A note on general observations

about the candidate including

his/ her professional achievement,

etc., if any

CONFIDENTIAL

(Please attach separate sheet, if required.)

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6. My rating of the candidate in Following trials (please tick):

Analytical Ability

Experimental Skills

Motivation

Written and Oral Expression

Leadership & Initiative

Teaching Ability

Sincerity & Dedication

7. To summarize, I would like to say that the applicant (please tick) :

is likely to become a brilliant scholar or an outstanding leader in his/ her chosen field.

is likely to do very well in the Post Graduate programme.

is likely to perform satisfactorily.

is not a good prospect.

8. My recommendation:

I recommend him/ her enthusiastically

I recommend him/ her

I do not recommend him/ her

Name of the Referee ________________________________ Signature ________________________________

Designation/ Position _______________________________ Date ____________________________________

(with Name & Address

of Organization) ________________________________________________________________________

Address ________________________________________________________________________

_________________________ Pin Code__________Fax : ____________________

Telephone No. (with STD code) _______________ (Office)______________(Cell)_________________

Professional qualification of the Referee _________________________________________________________

Please mail this form directly to : The Asst. Registrar (Exam), Indian Institute of Information Technology Allahabad

Devghat, Jhalwa, Allahabad -211 012 (U.P.), INDIA.

Note: Kindly write Application for MBA(IT)/Dual Degree MBA(IT) - Ph.D. on the envelope as applicable.

Excellent Good Unable to judge Fair

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IIIT-ALLAHABAD 2014

MEDICAL EXAMINATION REPORT

GENERAL EXPECTATIONS

Candidates will have good general physique with

a) Normal vision. In case of defective vision, it should be corrected to 6/6 in both eyes. b) Normal Hearing. Defective hearing should be corrected. c) Normal Heart and lungs and having no history of mental disease or epileptic fits.

PERSONAL HISTORY

1. Name

2. Parent/ Guardians Name: (a) Fathers Name . (b) Mothers Name .

3. Age: Years .. Months

4. Sex:.. Blood group

5. Identification Marks on the Body: (This can be a mole or scar)

6. Major illness / operation: (Specify nature of illness / operation.)

7. Allergies if any:

8. Any Chronic illness for which he/she is taking treatment: . (Eg. Diabetes, Asthma, Epilepsy, Kidney disease, Bleeding disorder, etc.)

9. Any kind of disability:

MEDICAL CERTIFICATE (To be issued by qualified doctor not less than MBBS)

(The following are to be filled by the Medical Officer conducting the medical examination at the candidate side.)

1. Height :cm. 2. Weight:kg.

3. Skin .. 4. Ears/Hearing:

5. Vision without glasses :

a) Right eye : .. Left eye :.

b) Colour Blindness :

c) Correction of vision through glass if any please specify :

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6. Respiratory system : 7. Nervous system :

8. Heart : 9. Abdomen :

a) Sounds :.. a) Liver: .

b) Murmur :. b) Spleen :

10. a) Hernia : b) Hydrocele :

11. Any other health issue :

12. Basic Path. Investigations (includes Blood Exam and Urine Testing:Hb, TCL, DLC, FBS, Urine-R &

M, GPRH):. (From a certified & recognized lab or it can be taken from the IIITA health centre for which Rs.250/- will be charged

additionally.)

___________________________ ____________________________

Signature of the Medical Officer Signature of the Candidate

Full Name :.

MCI Registration No.

Official Seal :.

Date :

MEDICAL CERTIFICATE (To be issued by IIIT-A Health Centre in Allahabad. Not to be filled by candidate)

Certified that .

son/daughter of

a) Fulfills the prescribed standard of physical fitness and is FIT for admission to MBA(IT)/ Dual Degree MBA(IT)-Ph.D. Program offered by IIIT-A.

b) does not fulfill the prescribed standard of physical fitness and is unfit / temporarily unfit to admission due to following defects :

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Signature of the Medical Officer at IIIT-A

Declaration

I hereby declare that I am not suffering from any disease other than mentioned in the medical

report. In case if any other disease is found for which I am taking treatment for long time and that is

not reported to the Institute at the time of admission then the Institute will not bear the cost of

treatment.

_______________________

Signature of the Candidate

Note: Institute is not liable for the chronic disease treatment which required the prolonged/ lifelong

treatment.