APPLICATION FORM - PGDMAPPLICATION FORM - PGDMAPPLICATION FORM - PGDM

Paste yourrecent

stamp sizecoloured

photograph

Name Mr./Ms.

Father’s Name

Mother’s Name

Father’s Profession & Address

Phone No.:

Phone No.:

E-mail.:

E-mail.:

Mobile No.:

Mobile No.:

Mobile No.:

Permanent Address with PIN Code

Present Address for Communication with PIN Code

Instruction :-• Read the form carefully before filling.• Filling of the form does not ensure admission.• Admission will be confirmed only after receipt of full fees.• Refer to the checklist for submission of documents.• Pending documents, if any should be submitted within 15 days of taking admission.• Please submit a copy of photo identity proof and residential address proof.

Date of Birth DD MM YY Category (SC/ST/OBC/GENERAL)

Sex Marital Status Hostel Accommodation Required Yes NoM F

Academic Qualification

Form No. :

Reg. No. :

Roll No. :

Phone No.:

E-mail.:

Mobile No.:

Mother’s Profession & Address

Phone No.:

E-mail.:

Board/University/Institute Year of passing % Marks Obtained Main SubjectName of Examination

High School

Intermediate (10+2)

Graduation

Any Other

Designation :

Company Name & Address:

Qualification:

Designation :

Company Name & Address:

Qualification:

JAIPURIA INSTITUTE OF MANAGEMENT STUDIESShakti Khand-IV, Indirapuram, Ghaziabad-201012 (U.P.), India

Phone : +91-0120-488 1100 Mobile : 9717335551,9891788383E-mail : pgdm@jaipuria.edu.in

Dy. Registrar Registrar

ADMISSION OF THE CANDIdate is entered in records and Roll No._______________________is allotted.

For use of Registrar office

( Signature of Manager Accounts)

Received a sum of Rs..................................................(.....................................................................................................) vide DraftNo..............................................Dated ...............................Drawn on................................................... ..........................vide ReceiptNo................................................................................Dated............................................

For Accounts Office use only

DirectorAcademic Coordinator

The Candidate is eligible and admission is granted.

For Office use only

Remarks

Admission Councellor(Name)

Admission Incharge

For Admission Cell use only

Date :...........................

Name :........................... Name :...........................

Signature of Father/Guardian Signature of Applicant

I hereby declare that the information given in the application form is true to the best of my knowledge and belief. If any information is found to be wrong, I shall be liable for action. I hold myself responsible for the due and prompt payment of fees.

DECLARATION

Signature of ApplicantHobbies & Extra-curricular activites

Period Name of the Company Position Responsibility

Professional Qualification Experience & Company Name

CAT Roll No. Score Percentile

MAT Roll No. Score Percentile

UPSEE Roll No. Score Percentile

OTHERS Roll No. Score Percentile

Entrance Examination Details

APPLICATION FORM - PGDMAPPLICATION FORM - PGDMAPPLICATION FORM - PGDM

How did you find out about Jaipuria Institute of Management Studies”. Please specify the source.

Alumni: _______________________________________________(name)

Friend/Relative/Parent: _________________________________(name)

Website: _____________________________________________(name)

Coaching Institute: ____________________________________(name)

Newspaper: ____________________________________________(name)

Magazine: _____________________________________________(name)

Other(s), Pls. specify: ___________________________________(name)