KIRLOSKAR INSTITUTE OF ADVANCED MANAGEMENT STUDIES

APPLICATION FORM FOR PGDM (2013 2015)

KIAMS Application No.____________ (Filled by KIAMS) Name of the Applicant (in full and in block letters) Fathers Name: Mothers Name CAT: Reg No:SR XAT ID: Paste recent photograph of Applicant Occupation: Occupation:

CMAT : Roll NO:

Date of Birth

Day

Month

Year

Age

Gender M/F

Address for Communication

Permanent Address

City: Pin: Telephone No: (including STD Code) Mobile No:

State:

City: Pin: Telephone No: (including STD Code) Mobile No:

State:

Email Id : (Registered with CAT/XAT/CMAT)

Academic Details
Examination School/College/University Name of Specify CBSE/ICSE/State/Others the Degree Marks (%) / Grade Point Specialization Year of Passing

10 / Matriculation 12 / PUC or equivalent Bachelor's Degree (If not yet completed give latest Marks & date of completion) Any other Qualification/s
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Work Experience Yes

No

If Yes, Number of Months :

Details of Work Experience (if applicable)

Name of the Company/ Organisation Details of work experience Employment from & to date From: To : Designation Responsibilities

From: To :

Past Achievements: Please list a max of five of your achievements. (academic, non academic, personal, etc.)
Attach extra sheet if applicable. Sl.No 1 2 3 4 5

Achievements

Your Preference of Centre for Group Work / Interview (please tick any one) :
New Delhi Ahmedabad Cochin Lucknow Hyderabad Indore Bangalore Kolkata Harihar Bhubaneswar Pune

Preference of Study Campus (Rank in order of preference) :

Harihar Pune

I confirm that to the best of my knowledge the information contained in this application is true and accurate. I have gone through the contents of the Prospectus and agree to all the conditions stipulated therein and if admitted, will also abide by the rules and regulations of KIAMS as may be in force from time to time.

Date :

Place :
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Signature of Applicant

Please send the completed application form to reach us before 15 March 2013 by Courier / Speed Post / Regd. Post to the following address along with a DD of ` 400 in favor of Kirloskar Institute of Advanced Management Studies payable at Harihar/Davangere. Also send a self attested copy of your CAT/XAT/CMAT score card (downloaded copy from the Internet / Photocopy) after getting the results from IIM/XLRI/AICTE. The Office In-Charge Admissions

KIRLOSKAR INSTITUTE OF ADVANCED MANAGEMENT STUDIES

Yantrapur P.O., HARIHAR 577 601 (Karnataka India) Telephone : (08192) 241269, 241483, 241486 Fax : (08192) 241270 E-mail : admissions@kiams.ac.in, Visit: www.kiams.ac.in for detailed information