INSTITUTE OF MANAGEMENT TECHNOLOGY

PGDM/MBA Admissions - 2011 Please affix your

Recent color
photograph
PERSONAL DETAILS FORM

IMT APPLICATION NO

A. CAMPUS PREFERENCE (Put 1,2,3,……)

IMT –Ghaziabad
IMT -Nagpur IMT - Hyderabad IMT - Dubai
PGDM DCP

B. FOR CANDIDATES (Sections B and C. to be filled in Block Letters only)

(ALSO FILL IN DETAILS OVER LEAF)
Name :

Father’s Name :

CAT Test Registration No :

Date of Birth : Age as on May 31, 2011: &

D D M M Y Y Years Months
B.1 Background:
B.1.1 Academic:
Graduation/Post Graduation Degree *: -----------------------------------------------------------------------------------------------------------------------------------------------------------

Specialization at Graduation/Post Graduation level: -----------------------------------------------------------------------------------------------------------------------------------------

* Graduation Degree (BA / B.Com / B.E./ B. Tech. / B.Sc./BBA/BCA/ Hotel Mgmt. /BIT/ MBBS. etc)

B.1.2 Work Experience: (If applicable)

No of Years (As on January 31, 2011) : Year (s) & Months

Functional Area of Experience……………………………………………………………………………………………………………………………………………….

Name of the Present Organization: ……………………………………………………………………………………………………………………………………….....

B.1.3 Ranks / Scholarship (International/National//State level only):

……………………………………………………………………………………………………………………………….………………………………………………...

…………………………………………………………………………………………………………………………………………………………………………………

B.1.4 Extra Curricular Activities (International/National//State level only):

1. ……………………………………………………………………………………………………………………………….……………………………………………...…

2. ……………………………………………………………………………………………………………………………………………………………………………...….

B.1.5 Hobbies:
1. …………………………….. …………………2. ……………………………. …………… 3… ……………………………………. 4.………………………………...

Please See Overleaf

Page 1 of 2
C . FOR CANDIDATES

C.1 Educational Qualifications

Year of Board / University Rank in the

Degree Name of College / Institution %age of Marks Board/University
Passing (Full Name)
Xth

XIIth

I Year
II Year
Graduation III Year
IV Year
Aggregate
Post Graduation

C.2 Work Experience (if any):

Organization Job Profile Duration

C.3 Purpose of pursuing PGDM/MBA Programme:

…………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………
D.4 Medical History:

Details of any major ailments (which requires hospitalization and / or continuous treatment

__________________________________________________________________________________________________________________________

Present status of ailment (if any)

__________________________________________________________________________________________________________________________

Physical Disability (if any)

__________________________________________________________________________________________________________________________

Are you or were under any continuous medication? If yes, give details.

_________________________________________________________________________________________________________________________

I declare that all of the above information provided by me in this form are correct to the best of my knowledge and belief.

Date: Signature of the Candidate

Page 2 of 2