Application No: IEMR/PGPM/1113/__________ (Official use only)

Institute of Energy Management and Research

143-144, Udyog Vihar, Phase IV, Gurgaon 122 015, Haryana, INDIA
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Application Form for Post Graduate Program in Management 2011-13 Affix Passport
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1. Name

2. Father's Name

3. Date of Birth (DD/MM/YYYY)

5. Nationality

6. Mailing Address

Pin

7. Tel No. (Landline) (with STD code)

(Mobile)

8. Email ID
9. Academic Record
Qualification Degree Discipline* School/College Board/University Year % /CGPA

Post- Graduation (if any)

Graduation**

Higher Secondary (XII)

Secondary (X)

* Branch of Engineering/Science/Commerce/Arts/Other
** If appearing in current session, please write the cumulative grades excluding final semester

10. Work Experience

Duration
Organization Designation Nature of Work
From To

11. Aptitude Test Results

Test Name Composite/Total Score Composite/Total Percentile Date Taken
CAT
MAT
XAT
GMAT

Have not given any of the above tests but willing to appear for IEMR Aptitude Test (please tick the the box on the right)
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Application Form for Post Graduate Program in Management 2011-13

12. Special Achievements

a. Academic Honors 1.

2.

b. Extracurriculars 1.

2.

c. Others (please specify)

13. Choice of City for Personality Bangalore Chennai Delhi

Assessment (Tick only one box) Hyderabad Kolkata Mumbai

14. Application Fee Payment if by Demand Draft

Details (Rs.1000 Only) DD No: __________________________ Bank_____________________________________ Date________________

if by Electronic Transfer
Transaction No: __________________ Bank_____________________________________ Date________________

Declaration: I certify that the information provided in this application is correct.

Place :__________________________________ Applicant’s Signature :___________________________________

Date : __________________________________ Applicant’s Name :___________________________________

Instructions to fill up the application form

1. Write in block capital letters using black ink in the boxes provided.
2. Provide all the information required. Incomplete applications may be rejected.
3. Affix your passport size photograph in the space provided with your signature across the photograph.
4. Attach a copy of your CAT/MAT/XAT/GMAT score card.
5. Student who have not taken any of the listed Aptitude Tests can submit their application form indicating their interest
in taking the IEMR Aptitude Test. Shortlisted applicants would be informed about the time and venue for the same.
6. Enclose a non-refundable demand draft for Rs. 1000 drawn on “Institute of Energy Management and Research” and
payable in New Delhi.
7. Indicate the demand draft number, bank name and date in the space provided in the application form.
8. In case of any queries please write to admissions@iemr.in or call +91 124 4780010
9. Completed application form along with all the attachments may be couriered, posted or hand-delivered to:
Admissions Office
Institute of Energy Management and Research
143-144, Udyog Vihar, Phase IV
Gurgaon 122 015, INDIA
Ph: +91 124 4780010
Fax: +91 124 4780001