INSTITUTE OF RURAL MANAGEMENT ANAND

Written Test Application Form 2012

Payment Particulars Mode of Issuing Payment Authority Offline IMS 1. Full Name of Applicant: 2. Father's Name: 3. Address Date 05-09-11 Amount 1000 Number delhi - connaught place/250046

Form No: 33257

*33257*
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PRACHI SHREE LATE MR. ANAND KUMAR JHA 14B, VASUDHA APARTMENT, SECTOR-6, VASUNDHARA GAZIYABAD UTTAR PRADESH PIN: 201011 Email: prachishree59@gmail.com Phone: 0120 2699426 Mobile: 8826726445 05-08-1991 Female General Completed Graduation Business Administration

4. Date of Birth: 5. Gender: 6. Category: 7. Education status: 8. Discipline:

9. Percentage at Graduation: 68.10 10. Percentage at PG: 11. Choice of Test Centre: 12. Work Experience: N.A. DELHI (No change will be allowed. Right of allocation rests with IRMA.) 0 month(s) (as on 31-7-2011)

13. Programme applied for: Programme in Rural Management 14. Sponsored Candidate?: 15. Yearly Family Income: 16. State of Domicile: No <1,00,000 Bihar

17. Source(s) of information about admission. Economic and Political Weekly, PrepTalk, Management Compass, The Hindu, IRMA Website, The Times Of India, IRMA Poster on Noticeboard, Friends & Relatives, The Economic Times, Pagalguy.com and Business & Management Chronicle 18. Do you want us to share your score with any other Institute associated with IRMA? No 19. Declaration
I declare that all the information contained in this form is correct. I shall provide documentary evidence, if required, wherever applicable. I understand that, if selected, my admission will be provisional; it will be confirmed only if I fulfil the eligibility criteria set for the admission. In the event of any false information appearing in this form or in the event of my failure to provide necessary certificates, my admission will stand automatically cancelled.

Date: _________________

Signature of Applicant:

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 Sign in the box given above. It is compulsory to send this application form along with payment chalan/receipt to IRMA Admissions Office, Anand-388001, Gujarat.