INDIAN INSTITUTE OF MANAGEMENT CALCUTTA

POST GRADUATE DIPLOMA IN MANAGEMENT (PGDM) AND POST GRADUATE DIPLOMA IN COMPUTER AIDED MANAGEMENT (PGDCM) APPLICATION FORM FOR THE SESSION 2010-2012 PGDM PGDCM

Affix a recent passport size photograph

Please write (1) in the appropriate box, if you have applied for only one programme. If you have applied for both the programmes, please write (1) for the programme of your first choice and (2) for the programme of your second choice. Name: ___________________________________________________________________________________ (IN CAPITAL LETTERS, as recorded in your school leaving certificate)

R
CAT Registration No.

General NC-OBC SC ST DA+ ________________________________________________ Category (Tick) If NC-OBC, SC, ST or DA, attach necessary certificate(s) Indian Others ________________________ Nationality (Tick) Date Month Year_ Date of Birth

Single Married _________________________ Martial Status (Tick) Mailing Address:

Pin code: Landline No.: E-mail ID: Interview City (Tick): BANGALORE KOLKATA MUMBAI NEW DELHI Mobile No.:

Fathers Name:________________________________ Mothers Name:_______________________________ Education Father Mother Annual Income of family including the Applicant*(Rs.): _________________ Financial Year: _______________ Family Size: ____________________ Annual Income of the Applicant (Rs.): ___________________________ Guardians Name: _______________________________________________ Relationship: ________________ Mailing Address: Pin code: Landline No.: E-mail ID: _________________________________________________________________________________________
+ Differently Abled *Please ensure the validity of self and family income statements as they may be subject to verification for internal administration.

Occupation

Designation

Annual Income (Rs.)

Mobile No.:

ACADEMIC RECORD
1. Pre-Bachelor Degree Examination: Stream during classes 11 12: _______________________________________________________________ Class Name of the School / Board Year of Total Maximum Marks Percentage Division & University Passing Marks Obtained 10th 12th 2. Bachelors Degree Examination: A. Discipline (Tick): Arts Commerce Engineering Science Others

If Others, please specify: _____________________________________________________________________ Specialization in Bachelors Degree: _____________________________________________________________ B. Bachelors Degree Examination (if completed): Attach an attested copy of the final mark-sheet. Degree Name of College / Year Total Maximum Total Marks/ CGPA Percentage Institute & University From Obtained To Marks / CGPA

Class

C. Bachelors Degree Examination (if not yet completed): i. Attach attested copies of all mark-sheets received so far. ii. A certificate from the college/institution certifying that you have obtained at least 50% marks or equivalent (45% in case of candidates belonging to SC, ST and DA category) based on the latest available grade/marks. The proforma of the certificate is enclosed. Degree sought: ___________________________ Institute / University: ________________________________ Expected date of completion of final examination including practical / viva / assignments / projects: Month: __________________________________ Year: ____________________________________________ Years of Attendance (Bachelors Degree Examination, if not yet completed): Year From To Total Maximum Marks / CGPA Marks / CGPA Obtained 1st 2nd 3rd 4th 5th Total Percentage

3. Masters Degree Examination (if completed): Degree Name of College / Year Total Maximum Total Marks/ CGPA Percentage Institute & University From Obtained To Marks / CGPA

Class

4. Other Professional Degree / Diploma (if completed): _________________________________

ACADEMIC RECORD GIVEN ABOVE ATTESTED BY (MANDATORY Please see Point No. 10 under Instructions)

______________________ Name

_______________________ Designation & Office Seal

_____________________ Signature

Work Experience: (Upto January 31, 2010 in chronological order. Please attach a separate sheet if required)

Do not include training/project work/work done as an integral part of curricular requirement. State work experience after Graduation only. Attach copies of experience certificates or first & last pay slips. In case you are self-employed or employed in a family business or in a company not listed in NSE or BSE, attach a note detailing the business (including turnover and profit) and the nature of your experience. DESIGNATION JOB PROFILE DURATION (MONTHS) TOTAL SALARY (PER MONTH) REASONS FOR LEAVING

ORGANISATION

Total Work Experience as on January 31, 2010: ______________________________________________________________________ (in completed months).

Extra Curricular Activities in College / University: Nature of Activity Honours / Award & Prizes, if any

Extra Curricular Activities at District / State / National Level: Nature of Activity Level* Honours / Award & Prizes, if any

* Mention District / State / National Level List out your hobbies (not more than two) with brief description:

Career Goals: (Do not write more than 60 words):

Academic Distinctions / Prizes / Awards / any other useful information:

DECLARATION: I declare that the information given by me in this application form is true and complete in all respects to the best of my knowledge. I understand that suppression of facts or false information may lead to rejection of my application at any stage of the selection process. I also understand that the decision of the Admissions Office of IIM Calcutta in any matter related to the selection process is final and binding on me.

_______________________ Place

______________________ Date

________________________ Signature of Applicant

INSTRUCTIONS
1. This Application Form should be completely filled in and must be handed over to the interview panel during the interview. The CAT 2009 Admit Card must be presented to the interview panel for verification. You also need to bring at least one acceptable form of photoidentification. Acceptable forms of photo identification are Drivers license, Passport, PAN Card, Voter ID, College ID, Employee identification card, or a notarized Affidavit with Photo, Signature, Date of Birth and Residential Address. NC-OBC / SC / ST candidates are required to submit a certificate (proforma enclosed) duly signed by the appropriate authority along with the application form. Candidates are also required to bring the original certificate for verification at the time of interview. Only certificates from appropriate authorities designated by the appropriate Government will be considered. Differently Abled (DA) candidates are required to submit a certificate (proforma enclosed) duly signed by the appropriate authority as per the Persons with Disability (PWD) Act 1995 along with the application form. Candidates are also required to bring the original certificate for verification at the time of interview. Please ensure the correctness of the self and family income statements as they may be subject to verification for internal administration. The original academic certificates/mark-sheets must be produced at the time of interview for verification. Please bring the attested copies of all mark-sheets and certificates. Necessary evidence in support of work experience must be attached along with the application form and also produced at the time of interview (Certified record of experience or first and last pay slips). If evidence of work experience is not produced during the interview, the work experience will be taken as NIL. Necessary evidence must be produced in support of extra curricular activities at the time of interview. Wherever letter / point grades are used, their percentage equivalents should be specified. A certificate from the relevant University / Institute must be enclosed indicating the conversion formula. If such a conversion is not possible, mention it below the marks columns and enclose a certificate from the relevant University / Institute to this effect. Academic records in the Application Form can be attested by the Registrar, Principal, Head of the Department or a Gazetted Officer (Central or State Govt.). In the case of letter or point grades or if applicants are in their final year, the attestation has to be done by the Registrar, Principal, Director or Head of the Department. Attestation of academic records in the Application Form is mandatory.
The Application Form and proformas of certificates can also be downloaded from the Institutes website (www.iimcal.ac.in).

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