INSTITUTE OF RURAL MANAGEMENT ANAND

Written Test Application Form 2013

Payment Particulars Mode of Issuing Payment Authority Offline SBI 1. Full Name of Applicant: 2. Father's Name: 3. Address Date 09-08-12 Amount 500 Number 026729561

Form No: 30152

*30152*
Photo

NAVEEN KUMAR LACHHU RAM R-123 MANGOL PURI NEW DELHI DELHI (U.T.-NCT) PIN: 110083 Email: naveengangwal@yahoo.co.in Phone: 919711 919711801686 Mobile: 9197118016 23-03-1991 Male SC / ST Completed Graduation Business Administration 69.20 71.80

4. Date of Birth: 5. Gender: 6. Category: 7. Education status: 8. Discipline: 9. Percentage (10th): 10. Percentage (12th):

11. Percentage at Graduation:71.10 12. Percentage at PG: 13. Choice of Test Centre: 14. Work Experience: N.A. DELHI (No change will be allowed. Right of allocation rests with IRMA.) 0 month(s) (as on 31-7-2012)

15. Programme applied for: Programme in Rural Management 16. Sponsored Candidate?: 17. Yearly Family Income: 18. State of Domicile: 19. Exemption from Exam: No 1,00,001 to 2,00,000 Delhi (U.T.-NCT) Not Applicable

20. Source(s) of information about admission. Friends & Relatives 21. Do you want us to share your score with any other Institute associated with IRMA? Yes 22. Declaration
I declare that all the information contained in this form is correct. I shall provide documentary evidence, if required, wherever applicable. I understand that, if selected, my admission will be provisional; it will be confirmed only if I fulfil the eligibility criteria set for the admission. In the event of any false information appearing in this form or in the event of my failure to provide necessary certificates, my admission will stand automatically cancelled.

Date: _________________

Signature of Applicant:

Paste your photograph in the given place. Sign in the box given above. It is compulsory to send this application form along with payment chalan/receipt to IRMA Admissions Office, Anand-388001, Gujarat.