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Management Development Institute Gurgaon

Application Form
Application Id:
MD3072239100
Payment ID.
MDI63712c48030e9449

1. Personal Information:
Name : ASHUTOSH CAT Registration No. : 22107600
Gender : Male Nationality : Indian
Category : GENERAL Date of Birth : 10 November, 1999
Educational Background : ENGI Other Educational Background : N/A
Family Annual Income : Upto 8,00,000 PWD : No
How did you come to know about MDI : Newspaper/magazine Other Details : N/A
2. Permanent Address:
Street/Area : Jagdispuri Lane No 1 , Mithanpura Chowk Muzaffarpur, Jubba Sahni Park, Muzaffarpur
Post Office : Ramna District : Muzaffarpur
PIN/ZIP code : 842002 State : Bihar
Landline No. : India Mobile No. : 9431633290

3. Communication Address:
Street/Area : Jagdispuri Lane No 1 , Mithanpura Chowk Muzaffarpur, Ubba Sahni Park, Muzaffarpur
Post Office : Ramna District : Muzaffarpur
PIN/ZIP code : 842002 State : Bihar
Landline No. : India Mobile No. : 9431633290
Registered Mobile No. : 9304005616 Registered E-mail : ashu10111999@gmail.com
Father's Name : Binod Kumar Jha Mother's Name : Kiran Jha
4. Educational Qualification:
Marks CGPA
Name of Examination Year Board/ University Obtained/ Obtained / Percentage
Max Marks Max CGPA
10th 2014 Central Board of Secondary Education, Delhi 10 / 10 95
12th 2016 Central Board of Secondary Education, Delhi 430 / 500 86
BE/B.Tech 2021 Visvesvaraya Technological University, Karnataka 8.25 / 10 75
(Engineering)

5. Experience Details:

Sl Name of Employer Designation Monthly Period Period Total Exp Nature of Work
No Employer Address /Position Remuneration From To

1 Ganit Business Chennai Data Analyst 56000 08-2021 01-2023 18 BI Developer and Conducting Interviews
Solutions Months for Campus Placement

Total Experience : 18 Months

 6.CHANGE PASSWORD
Extra-Curricular (HTTPS://MDI.UCANAPPLY.COM/UNIVER/PUBLIC/CHANGEPASSWORD?APP_ID=UELZMDAWMDA3OQ==)
Activities
Please mention inter-collegiate, institute and higher level activities only. These may include games and sports, cultural, literary and similar other activities.
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National/ International State/ District IntraSchool/

IntraCollege

SPORTS - - -

OTHER Yes - Yes

Other Activity Have volunteered at College Tech fest. Have been in the top 13 percentile in
National Creativity Aptitude Test. Have been awarded a Certificate of
Distinction in college. Have done various certi

7. Documents Attached with the Application

(1) 10th Marksheet (https://ucanapplym.s3.amazonaws.com/laraveldemo/PIY0000079/doc/3072239_1668360516.pdf), (2) 12th Marksheet

(https://ucanapplym.s3.amazonaws.com/laraveldemo/PIY0000079/doc/3072239_1668360552.pdf), (3) Bachelors Degree
(https://ucanapplym.s3.amazonaws.com/laraveldemo/PIY0000079/doc/3072239_1668360966.pdf), (4) CAT Admit Card/GMAT Score Card
(https://ucanapplym.s3.amazonaws.com/laraveldemo/PIY0000079/doc/3072239_1668360691.pdf), (5) Photo Identity Card Document (PAN Card, Voter ID Cart, Driving
License etc.) (https://ucanapplym.s3.amazonaws.com/laraveldemo/PIY0000079/doc/3072239_1668360540.pdf), (6) Extra-Curricular Activities
(https://ucanapplym.s3.amazonaws.com/extracurricular/PIY0000079/3072239/MDI1674474612Y851.pdf) , (7) Ganit Business Solutions
(https://ucanapplym.s3.amazonaws.com/laraveldemo/PIY0000079/Experience/MDI1674472324Y286.pdf) ,

8. Campus Course Preferences

Preference No. Campus-Course Name

1 GURUGRAM-PGDM

2 GURUGRAM-PGDM HR

3 GURUGRAM-PGDM IB

DECLARATION:
I have carefully read the instructions and agree to abide by the decision of the respective Institutes authorities for my final selection for the programme.
I ASHUTOSH certify that the particulars given me in the form are true to the best of my knowledge and belief.I do understand that the data recorded in CAP form
shall be used for the merit list preparation. In case of discrepancies, either of the CAT data or CAP form data shall be used by MDI as per their discretion.

Place: Date: 13-11-2022

Printed on : 09-03-2023 06:29 PM

(Signature of the candidate)
University
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PASSWORD Online Payment) Student Copy (Receipt for Online Payment)

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Receipt - Admission 23-24 Receipt - Admission 23-24

Application No: MD3072239100 Application No: MD3072239100

Challan No: MDI63712c48030e9449 Challan No: MDI63712c48030e9449

Payment Date: 13-11-2022 11:13 PM Payment Date: 13-11-2022 11:13 PM

Name: ASHUTOSH Name: ASHUTOSH

Email ID: ashu10111999@gmail.com Email ID: ashu10111999@gmail.com

DEPOSIT DETAILS (INR) DEPOSIT DETAILS (INR)

Sl. No. Particulars Amount (Rs.) Sl. No. Particulars Amount (Rs.)

1 Total Amount (Rs.)3000 1 Total Amount Rs.3000

Amount in Words : Rs.Three Thousand only Amount in Words : Rs. Three Thousand only

Depositor Signature Depositor Signature

Non refundable Non refundable

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