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Form No:

APPLICATION FORM

(For Admission to Two years full time M.B.A. Programme 2013 2015)

Registration Number: of year 2013 2015.

Closing Date: 12nd April 2013, Friday

SESSION(20132015)

The application form properly filled and signed by the applicant together with attested copies of the pass certificates

mark sheet of all examinations passed including CAT / CMAT score card shall be send to the office of Dean (Researc

& Consultancy), PG & Research Section, National Institute of Technology, Durgapur. Mahatma Gandhi Avenu

Durgapur713209,West Bengal so as to reach on or before closing date. Incomplete Application Form and Filled u

Form without supporting Documents will be summarily rejected.

1. Name of the Applicant (In block Letters)

2. Date of Birth:3. Nationality4. Gender

Male Female (tick the appropriate box)

5. State to which the applicant belong:6. Name of Father / Guardian7. Present Mailing Address:

P I N N 8. Phone No / Mobile no:9. Permanent Address:

P I N N 10.E-Mail:

11.Whether the Applicant belongs to Scheduled Cast / Scheduled Tribe / OBC / PH (Certificate from the competenauthority, not below the rank of Tahsider should be attached in support of the statement). For OBC Candidates cop

of certificate from a competent authority, not below the rank of Tahsildar, indicating the state regarding creamy laye

issued on or after 01/04/2012, is to be attached.

General SC ST OBC PH (tick the appropriate box)

D D M M Y Y Y Y

Affix a Recen

colour passport siz

photograph

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12.Details of Educational Qualification:School/College Exam Passed (Board

University)Year of passing Subject Studied Percentage

13. CAT Percentile Score: CMAT Rank: Score:14.Details of Industrial Experience, If any ( Vocational Training will not be considered)

Name of Employer From To Employed as Salary Drawn

15.Extracurricular activity:16.Whether the applicant is receiving any stipend / financial assistant for his study, If so give details:

17.Details of attested photocopy of certificates / documents attacheda.b.c.d.e.f.g.h.

18.Paid the DD of Rs. 1050.00 (Rs. 450.00 for SC / ST) for downloaded form from WebsiteDrawn in favour of National Institute of Technology Durgapur payable at State Bank of India, R.E College

Durgapur, bearing DD No: Dated:

19.Declaration by Applicant:I hereby declare that all the particulars stated above are correct. I understand the association whether active or passivwith any unlawful organization is forbidden. If selected for admission. I promise to abide by the Rules and Regulatio

of the Institute.

Signature of Applicant (with date)

FOR OFFICE USE

Recommendation:

Signature of HOD, DMS