(For Office Use Only) Roll No. Application No.

: Last Date :

IIBM Institute of Business Management

ISO 9001:2000 Certified
Tel: 011-65478246, 9219514364, 9219514358 Campus : IIBM, 1 Beripura, Near Era Mall, Delhi Road, Meerut - 250002 (NCR) Tel: 0121-4016161, 4016162, 4016163 Fax: 0121-4006123

M.O. : ICR India 21, Paharpur Business Center, Nehru Place, New Delhi-19

Application for Admission

(Please fill up the form in CAPITAL LETTERS only and Tick Wherever necessary)
1. 2. 3. 4. 5. Name of the Candidate : Gender : Date of Birth : Father's/Husband's Name : Address for Communication : Male Female

Recent Passport Size Photograph

State 6. 7. 8. 9. Phone No. : (With Code) E-mail ID : Academic Qualifications : Whether employed or not :

Pin Code Mobile No.:

10. If Yes, specify the name and place of the Organization :

11. Examination Method preferred : 12. Courses Selected: Lean Six Sigma Black Belt

Postal Based

Email Based

Centre Based

Six Sigma Green Belt Six Sigma Master Black Belt Six Sigma Black Belt Lean Six Sigma Green Belt

Project Management Certification Total Quality Management ISO 14001 : 2004

CMMI Kaizen ISO 9001 : 2008

P.T.O. 1 IIBM

13. Course Fees : Services Tax (12.36%) : DD / Cheque No. & Date : Name of Issuing Bank : : Checklist: Application form properly filled and signed. Demand Draft / Cheque

4 passport size photograph. CV

DECLARATION I have read and understood the rules and regulations of IIBM Institute of Business Management given in the prospectus and I do hereby agree to abide by the same Place : Date : Rules and Regulation of the Institute
1. 2. 3. 4. 5. The Director of the Institute reserves the right to accept or reject an application without assigning any reason whatsoever. The necessary fee by DD / Cheque drawn in favour of "ICR India Certifications Pvt. Ltd." Payable at New Delhi/Meerut will have to be sent along with the filled up application form. No refund or adjustment of fee paid other than mentioned in the prospectus shall be made under any circumstance. In case of the rejection of an application, full fee paid will be refunded. The management of IIBM reserves the right to change the course details without notice as per the prevailing conditions. All disputes subject to Jurisdiction of Court in Meerut City Only .

Signature of the Applicant

IIBM