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Application Form

User Id: 6143336
CANDIDATES ARE REQUESTED TO RETAIN THE PRINTOUT OF ACKNOWLEDGEMENT PAGE FOR FUTURE REFERENCE.

Personal Details

Name of Candidate: SHAIK SHAFFI BASHA

Father's/Husband's/Guardian's
SHAIK BASHA
Name :

Mother's Name: SHAIK KARIMUN

Date of Birth: 22/Aug/1996 Candidate Gender: Male

State/Union Territory of
Category: General
Caste/Tribe:

Serial Number of caste/Tribe: Caste/Tribe Name:

Nationality: Indian Aadhar Card Number :

Person with Disability (PWD): No PWD Category:

Disability Percentage: Do you require wheelchair
support at the test centre?:
Would you be using a scribe for
the Test?: Would you be requiring the
Zoom Feature for the Test?:

Specific query on PWD Support:

Communication Address
Door No. 1/29

Address:
Main Road

Lakkavaram

Country: India

State/Union Territory: ANDHRA PRADESH Other State/Union Territory:

District: Prakasam Other District:

Town/City: Ongole Pin Code: 523264

Mobile Number: 9573440057 Email Address: shaffibasha2517@gmail.com

Mobile Number (Alternate) : 9912971946 Email Address (Alternate) : shaffibasha.shaik@gmail.com
Exam Centre City Preferences
Preferred City 1: Vishakapatnam

Preferred City 2: Vijayawada

Preferred City 3: Hyderabad

Preferred City 4 Nellore

Academics Details

SSC/10th Std/Equivalent Details
Aggregate marks: 93.83 Month/Year of Completion: April 2011

Total Marks Obtained : 563 Maximum Marks : 600

SSC/10th Std/Equivalent Board Andhra Pradesh Board of Secondary Education
Name

HSC/12th/Equivalent/Diploma Course Details
Course Type: HSC Aggregate Marks: 97.5
Total Marks Obtained: 975 Maximum Marks: 1000

12th/Equivalent Board Name: Andhra Pradesh Board of Intermediate Education

Duration of Diploma Course:

University/Board/Other Authority
Name:

Discipline: Science

Month/Year of Course
Month/Year of Completion: April 2013
Commencement:

First Bachelor Degree Details
Are you in the final year of Bachelor Degree? Yes

I have more than one Bachelor's Degree?

Have you completed Bachelor
Total Duration of Degree: 4 Year
Degree?
Current Semester: Semester-7 Aggregate Marks: 76.62

Type of University/Institution:
State University

State/Union Territory Where Andhra Pradesh
University is Situated:
First Bachelor Degree Details

University Name: J.N.T.U.

Name Of College: University College of EngineeringJNTUK

Degree Name: BTECH

Discipline: Engineering/Technology

Month/Year of Course Probable Month/Year OR
October 2013 April 2017
Commencement: Month/Year of Completion:

Second Bachelor Degree Details
Are you in the final year of Bachelor Degree?

Have you completed Bachelor Total Duration of Degree:
Degree?
Current Semester: Aggregate Marks:

Type of University/Institution:

State/Union Territory Where
University is Situated:

University Name:

Name Of College:

Degree Name:

Discipline:

Month/Year of Course Probable Month/Year OR
Commencement: Month/Year of Completion:

Master Degree Details
Do you want to enter Master No
Degree Details?

Master Degree Completion Status: Duration:

Current Semester: Aggregate Marks:

State/Union Territory of
Type of University/Institution:
University:

University Name:

Name of College/Institution:

Degree Name:

Discipline:

Month/Year of Course
Month/Year of
Commencement:
Completion:
Other Professional Degree Details
Have you completed any professional degree such as CA/CS/ICWA
No
without completing Bachelor's Degree:

Professional Inter Marks: Professional Final Marks:

Month/Year of Course
Month/Year of
Commencement:
Completion:

Work Experience Details

Automobiles/Auto-ancillaries Banking/Financial Services

Durables Engineering/Industrial

Fast Moving Consumer Goods
Information Technology
(FMCG)

Pharmaceuticals/Healthcare Retail

Others
Telecommunications

Total Work Experience (In months 0
as on 31st July 2016)

Programme Details

Programme Names Interview City Selected / Not

IIM Ahmedabad PGP Hyderabad Selected
(Interview City 1)

IIM Ahmedabad PGP
Bangalore Selected
(Interview City 2)

IIM Ahmedabad PGP-FABM Bangalore Selected

IIM Ahmedabad FPM Ahmedabad Selected

IIM Amritsar PGP Hyderabad Selected
IIM Bangalore PGP Hyderabad Selected

IIM Bangalore PGP EM Bangalore Selected

IIM Bangalore PGP PM Bangalore Selected

IIM Bangalore FPM Bangalore Selected

IIM Bodh Gaya PGP Bangalore Selected

IIM Calcutta PGP PGDM Hyderabad Selected

IIM Calcutta FPM Kolkata Selected

IIM Indore PGP Hyderabad Selected

IIM Indore PGP Mumbai Hyderabad Selected

IIM Indore EPGP Hyderabad Selected

IIM Indore FPM Indore Selected

IIM Jammu PGP Bangalore Selected

IIM Kashipur PGP Bangalore Selected

IIM Kashipur EPGPM Dehradun Selected

IIM Kashipur EFPM Kashipur Selected

IIM Kashipur FPM Kashipur Selected

IIM Kozhikode PGP Hyderabad Selected

IIM Kozhikode FPM Kozhikode Selected

IIM Lucknow PGP Hyderabad Selected

IIM Lucknow PGP ABM Hyderabad Selected
IIM Lucknow PGPSM Hyderabad Selected

IIM Lucknow FPM Lucknow Selected

IIM Nagpur PGP No Interviews for this programme Selected

IIM Raipur PGP Bangalore Selected

IIM Raipur PGPWE Raipur Selected

IIM Raipur EFPM Raipur Selected

IIM Raipur FPM Raipur Selected

IIM Ranchi PGDM Bangalore Selected

Bangalore Selected
IIM Ranchi PGDHRM

IIM Ranchi FPM Ranchi Selected

IIM Rohtak PGP Bangalore Selected

IIM Rohtak EPGP Hyderabad Selected

IIM Rohtak FPM Rohtak Selected

IIM Sambalpur PGP Hyderabad Selected

RGIIM Shillong PGP Bangalore Selected

RGIIM Shillong PGPEX To be decided Later Selected

RGIIM Shillong FPM Shillong Selected

IIM Sirmaur PGP Bangalore Selected

IIM Tiruchirappalli PGP Bangalore Selected

IIM Tiruchirappalli PGPBM Chennai Selected
IIM Tiruchirappalli FPM Trichy Selected

IIM Udaipur PGP Bangalore Selected

IIM Udaipur FPM Udaipur Selected

IIM Visakhapatnam PGP Hyderabad Selected

Payment Details

Payment Mode Amount Payment Status Payment Transaction Number Order ID

online 1700 S GSM34740246193 614333620160909151646912

DECLARATION

I have previewed the Application Form by clicking on the Preview Application Button and confirm that all the data reflecting in the Preview are
correct. I hereby certify that the information given by me in this Application Form is true to the best my knowledge. I certify that I fulfill the
CAT 2016 eligibility criteria and undertake to produce original documents whenever necessary and I will not demand any reschedule of exam. I
agree to abide by the declaration of the authorities regarding the eligibility of my application and understand that any misrepresentation or
omission of facts in my application may justify cancellation of my CAT 2016 application & scores. I understand that all disputes will be subject
to the territorial jurisdiction of city of Bangalore only.
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