APPLICATION FORM Two-year full time residential MBA Programme KIIT School of Management, Bhubaneswar

SECTION A: Centre & Scores 1. Mark your order of preference (1 for �rst preference to 6 for last preference) for Centre for

Group Discussion & Personal Interview (GD & PI) U

Bangalore Bhubaneswar Delhi Kolkata Mumbai Jamshedpur

2.

3.

Details of KIITEE-Management / CAT / MAT / CMAT / XAT/ GMAT / ATMA Scores

Applying through:

Apply For:

KIITEE MGT CAT MAT CMAT XAT GMAT ATMA

ID / Regn. No / Roll No. ……………………… Rank / Composite Score / Percentile …………………………

Paste your recent

passport size photograph

here (do NOT staple)

Index Number (for o�cial use only)

Please �ll up all the sections below in your own handwriting. (Incomplete or illegible application forms are liable to be rejected)

SECTION B: Key Personal Information (Please leave one box blank between two words)

4. Full Name (in block letters) 5. Father’s Name

6. Mother’s Name

7. Date of Birth D D M M Y Y Y Y

8. Gender (Tick whichever is applicable) 9. Marital Status ……………………………………………………………………………………………..…. 10. Category (Tick whichever is applicable)

Male Female

GENERAL OBC SC ST

MBA (Marketing/Finance/HR/Operations) MBA (Both Options)MBA (Business Analytics)

11. Nationality ……………………………………………………………………………………………… 12. Religion ………………………………………………………………………………………………

13. Mother Tongue ………………………………………………………………………………………………

14. Address for Correspondence (in block letters) PINCODE 15. Permanent Address (in block letters) PINCODE 16. E-mail Address Tel. No. (With STD Code). Mobile 17. Occupation of Parents Father…………………………………… Mother………………………………… 18. Total Annual Household Income (gross)…... …………………………………………………………………….. 19. Do you plan to avail a study loan for the course Yes No 20. In case of emergency, we can contact Mr./Ms./Mrs……………………………………………………………… Landline Phone………………………… Mobile …………………… Relationship with you …………………… 21. Whether physically challenged Yes No

Details (if the answer above is ‘Yes’) ……………………………………………………………………………………………………….

22. Blood Group ……………………………………………………………………………………………………… 23. If you have participated in any sports/games at State/National level, give details…………………………… 24. Details of Application Fee paid: Drawee Bank ……………. ……… DD No………….…Date………….…….

SECTION C: Education & Experience 25. Educational Details:

Name of the Examination

Board/ University

Name of the College/ Institute

Year of Passing

Stream Class % of Marks*

i. Matriculation/ Secondary School Examination

ii. +2/Higher Secondary/ Equivalent

iii. Degree

iv. Please indicate if you have appeared in any Degree exam. and result not declared

iv. Specify Post Graduate Degree, if any

* % of marks in aggregate, including optional. 26. Work Experience (write latest experience �rst; attach separate sheet, if necessary)

Name of the Organization

Duration Designation Responsibilities From

(Month/Year) To (Month/Year)

SECTION D: Other Information Please think very carefully before answering the question below. Ensure that each answer is AT LEAST 60 words long. 27. How do you expect MBA to bene�t you? ………………………………………………………………………………………………………………

………………………………………………………………………………………………………………

………………………………………………………………………………………………………………

………………………………………………………………………………………………………………

………………………………………………………………………………………………………………

28. Give an example of something that you did well. Why do you think you succeeded? ………………………………………………………………………………………………………………

………………………………………………………………………………………………………………

………………………………………………………………………………………………………………

………………………………………………………………………………………………………………

………………………………………………………………………………………………………………

29. Give an example of something you have failed in. Why did you fail? ………………………………………………………………………………………………………………

………………………………………………………………………………………………………………

………………………………………………………………………………………………………………

………………………………………………………………………………………………………………

………………………………………………………………………………………………………………

30. How did you come to know about KSOM ?………………………………………………………………………

Declaration

I certify that the information furnished in this application is true to the best of my knowledge and belief. My application may be rejected and admission cancelled if any information provided herein is found to be incorrect at any time during or after the admission. Signature of the candidate in full…………………………….. Place……………………… Date………………… Enclose a copy of the following documents and tick appropriate boxes Total documents attached………… 1. High School Certi�cate and Mark sheet.

2. 2.+2/HSC Certi�cate and Mark sheet

3. Graduation (B.A, B.Com, B.Sc, Engineering

etc.)Certi�cate and Mark sheet

4. Caste certi�cate, if applicable

5. Physically challenged certi�cate,

if applicable

6. Sports / Extra-curricular participation

certi�cate, if applicable

7. KIITEE MGT/MAT/ CAT/

XAT/GMAT/ATMA Score card.

8. College Leaving Certi�cate

9. Migration Certi�cate

10. Conduct Certi�cate

11. Any other, Please Specify

UFOR OFFICIAL USE

The candidate has been selected / waitlisted in the interview held on........................................................................ for MBA Programme. Payment Details

Fee Due Date Payment Date Amount DD Number DD Date Bank First Installment

Second Installment

Admission Permitted / Not Permitted

Admission O�cer Chairperson, Admissions Dean / Director, Admissions

Completed application along with enclosures should reach: Chairperson, Admissions KIIT School of Management, Campus-7 KIIT, Bhubaneswar-751024, Odisha, India Phone: +91-674-2725007 (D), Fax: 91-674-2725007, 2725278, 7894460016, 9937085344 (M) E-mail: HUadmission@ksom.ac.inUH, web site: HUwww.ksom.ac.in U