Five year Integrated Programme in Management at IIM Indore -Application 1

Last date for receipt of application at IIM Indore: April 10, 2013

INSTRUCTIONS
1. This application form is a key part of admission process and important for your selection. Complete and accurate information
are extremely important. Incomplete or false information will adversely affect your chances of selection.
2. Admission granted on the basis of false and / or misleading information will be ipso facto null and void.
3. In all matters relating to admission to the five integrated programme, the decision of the Institute's authorities will be final and
binding on the applicant.
4. No correspondence will be entertained from the applicant regarding his/ her non-selection.
5. Please submit your application so as to reach IIM Indore on or before April 10, 2013 along with attested copies of academic
marksheets/certificates
6. The application fee of Rs. 1000 (Rupees One Thousand only) shall be paid by Demand Draft (DD)/Bankers Cheque (BC) drawn
in favour of Indian Institute of Management Indore, payable at Indore

Application Fee Details;
Name of the Candidate Drawee Bank Branch Location



DD/BC Date DD/BC No Amount (Rs.)



(I) PERSONAL DATA

Name of the Candidate
(As given in the certificates)


Date of Birth Age as on June 30, 2013 (in
completed years only)
D D M M Y Y Y Y


Gender (Tick appropriate one)
Male Female


Category (Tick appropriate one)
General NC-OBC SC ST PWD/ DA
(Candidates belonging to NC-OBC/SC/ ST/PWD/DA need to submit valid certificate copy with the application)

Name of the Parents/ Guardian: Contact number Email


Mailing address:





City State PIN

Phone: Fax: Email:

INDIAN INSTITUTE OF MANAGEMENT INDORE
FIVE YEAR INTEGRATED PROGRAMME IN MANAGEMENT (IPM)
Commencing in July 2013

Affix your recent
passport size
colour photograph
here
Five year Integrated Programme in Management at IIM Indore -Application 2

(II) ACADEMIC QUALIFICATIONS
A. Provide complete and accurate information on examination marks in all columns.

B. Wherever you have received letter grades or grade points instead of marks, provide equivalent marks and attach a certificate
from competent authority explaining the method of conversion. Where such conversions are not possible, please provide an
explanatory note in the additional space provided at the end of this page. The Admission Committee's decision in such cases
would be final.

Schooling:

Standard Name of Board/ University Year Total Max.
Marks/
Grade
Total
Marks/Grade
Obtained
% Marks /
Grade
Obtained
Class/
Division/
Rank*
X Std / Secondary/
Equivalent




XI Std / Higher
Secondary/
Equivalent



XII Std / Higher
Secondary /
Equivalent



*Please produce certificates/ evidence if a rank is mentioned.


Standard From
(Yr)
To
(Yr)
Core subjects Marks/
Grade
obtained
Other subjects Marks/
Grade
obtained
No of
attempts

X Std /
Secondary /
Equivalent





XI Std / Higher
Secondary/
Equivalent







XII Std / Higher
Secondary/
Equivalent






Space for explanation of letter grades / grade points/ any other relevant information relating to academic qualification









Five year Integrated Programme in Management at IIM Indore -Application 3

(III) SAT-1 Score details

SAT-1 Score Card
(SAT- 1 scores obtained during January 1, 2012- March 31, 2013 are only valid)
Writing Section Critical Reading Section Mathematics Section Overall


Choice of Center for Aptitude Test (May 10, 2013):

Choice of Center for Personal Interview (May 28-31, 2013), if shortlisted:

(IV) SCHOLASTIC ACHIEVEMENTS

Scholastic Achievements: Please list scholastic awards or scholarships conferred on you during your School education at Secondary
and Higher Secondary or Equivalent level in curricular, co-curricular and extra curricular activities at district, state, and national level.
You need to produce certificates in support of your claim.















(V) CAREER PLANS
Why do you wish to go in for a management education through five integrated programme? (Limit your response to 100 words)




















AT Centre Preference
(Bangalore/Delhi/Hyderabad/Indore/
Kolkata/ Mumbai)
1 2 3



PI Centre Preference
(Bangalore/Delhi/Hyderabad/Indore/
Kolkata/ Mumbai)
1 2 3



Five year Integrated Programme in Management at IIM Indore -Application 4

(VI) MEDICAL HISTORY
Please state whether you have any existing physical disability or any chronic illness, including mental illness, which could affect your
studies at the Institute.




If you have suffered from any chronic illness, including mental illness, in the past, please provide details below:

Nature of illness When suffered Date of completion of
treatment
Remarks, if any
1.
2.
3.

It is mandatory for all applicants to ensure that they are medically fit for joining the programme and they shall get the medical
fitness certificate from authorised doctor/ hospital preferably from Government Hospitals.


(VII) DECLARATION
I clearly understand that if I am selected, I will be allowed to join the programme only if I satisfy all requirements of the programme
including the submission of a certificate at the time of registration from Principal of my school that except for declaration of results, I
have completed all requirements for obtaining XII Std / Higher Secondary/Equivalent qualification and that I would have to produce
evidence (mark sheet/ certificate) of having passed the XII Std/Higher Secondary/Equivalent examination on or before December 31,
2013. Non-fulfilment of these requirements will automatically result in the cancellation of the provisional admissions offer and no
refund of fee will be made.

I certify that the particulars given by me in this application are true to the best of my knowledge and belief. I understand that
admission granted on the basis of false and/ or misleading information will be ipso facto null and void. I agree to abide by the
decision of the institute authorities regarding my selection/ non-selection for the programme.

I also understand that commitment fee which I may pay are non refundable and no claim will be made by me or on my behalf for the
same.

I undertake to produce the following documents at the time of personal interview, if called for:
Original and attested copies of all academic certificates / marksheets / certificates from School authorities
evidencing proof of all claims made in this application.
Original and attested copy of reservation certificate in case of SC, ST and PWD/DA candidates
A duly signed copy of this application

Place: ______________________


Date: ______________________ _________________________
Signature of the applicant











PLEASE READ THIS FORM ONCE AGAIN AND MAKE SURE THAT YOU HAVE COMPLETED ALL
THE DETAILS RELEVANT FOR YOU AND HAVE COMPLIED WITH ALL REQUIREMENTS.
INCOMPLETE APPLICATION ARE LIABLE TO BE REJECTED
Send in your completed application form so as to reach this office latest by April 10, 2013 along
with DD/BC and photocopy of academic marksheet(s)
To,
The Admissions Office
Indian Institute of Management Indore,
Prabandh Shikhar, Rau-Pithampur Road,
Indore 453556