1. Name in Block Letters:

First Name* :

Middle Name :

Last Name* :

2. Sex* :

3. Date of Birth* :

4. Father's Name
     Husband's Name

5. Address for correspondence* :

Pincode* :

Phone No. :

Mobile No.* :

Fax :

Email Id* :

6. Highest Academic & Professional Qualification [Proposed][From Matriculation onwards]*

7. Professional experience [From the Current Experience]*

8. Primary Field of Interest:(Please mark 1,2,3 in the in order of preference)

9. Name of the IIM Chapter you intend to be attached

10. Documents to be submitted :

Qualification type :

SSLC Marksheet / Grade sheet :

HS [+2] Marksheet / Grade sheet :

Experience Certificate :

Diploma Marksheet / Grade sheet(Provision available to upload consolidated documents) :

BSc. Marksheet / Grade sheet(Provision available to upload consolidated documents) :

BTech / BE Marksheet / Grade Sheet other than metallurgy(Provision available to upload consolidated documents) :

Declaration by the Applicant:

I hereby declare that the information given in this application is true and correct to the best of my knowledge and belief. In case any information given in this application proves to be false or incorrect, I shall be responsible for the consequences.