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DEPARTMENT OF MANAGEMENT STUDIES

INDIAN INSTITUTE OF TECHNOLOGY DELHI


Certificate course in Business Management (Focus:Digital marketing)
(Under the aegis of the Continuing Education Programme)

Affix a recent,
Student ID:………………..
self attested
ENROLLMENT FORM
passport size
1. Name: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ photograph.
2. Date of Birth : _ _ /_ _ / _ _ _ _
3. Marital Status: Single Married Please do not
4. Nationality: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ staple
5. Correspondence address: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
________________ ____ ____ ________ _________________________
City _ _ _ _ _ _ _ _ _ _ _ _ State _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Pin Code _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Email address: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Phone No. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Mobile No. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
6. Permanent address: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
____ ____________ ____ ____ ____ ____ ____ ____ ____ ___________
City _ _ _ _ _ _ _ _ _ _ _ _ State _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Pin Code _ _ _ _ _ _ _ _ _ _ _ _ _ _
7. Parents Detail:
Father's Name _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Occupation: _ _ _ _ _ _ _ _ _ (M) _ _ _ _ _ _ _ __
Mother's Name: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Occupation: _ _ _ _ _ _ _ _ _ (M) _ _ _ _ _ _ _ _ _

8. Educational Qualification:
S.No. Exam/Degree College/Institute Year. Of Passing Percentage (%)

9. Current Employment Details (if Any?)

Service Self-Employed
Company Name: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ __ _ _ _ _ _ _
Designation: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Industry: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Employment Since: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Last Salary Drawn :(  ) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

10. Past Experience: (Please attach separate sheet if required)

PTO Page 1 of 2
S.No From To Name of Employer Department Designation

11. Payment Details:


Down Payment: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Amount (  ): _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
(In Words) Rupees _ _ _ _ _ _ _ _ _ _ _ _ _ _ DD/Ch. No. _ _ _ _ _ _ _ _ _ _ _ _ _ _
Dated _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Drawn on: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Branch: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Date: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Place: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Please ensure the following documents are enclosed with the enrolment form.
1. Copy of Resume
2. Two References

Applicant’s Signature

All communications shall be made to: (Signature)

Ms. Sapna Bhardwaj,


C/O Dr.Harish Chaudhry,
Room No. 605, Vishwakarma Bhawan,
Shaheed Jeet Singh Marg,
IIT Delhi, New Delhi-110016
011-26591170
www.iitd.ac.in/courses/stc_details www.ifehe.com

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