PROGRAM REGISTRATION FORM

IMT APPLICATION NO : 1903781

IMT ENROLMENT NO : 19A3HP630
(To be allotted by IMT)

nishant kumar
PGDM (Full Time)
nishantkumar@imthyderabad.edu.in

Personal Details
Date of Birth Mar 13,1995
Gender Male
Mobile Number 8210945647
Alternate Email nishantkumar@imthyderabad.edu.in
Address q.no.-706 new colony Muraidih p.o.- pochari Dhanbad
Blood Group O-
Aadhaar Card No 477147079618
Religion Hindu
Caste bhumihar
Category Open
Nationality Indian
Domicile Jharkhand

Educational Details
Course Year of Name of University/Bo (%)Marks Rank/Scolars Mode of
Completed Passing College/Instit ard hip Secured Study
ute
SSC 2010 DAV public 81.7
school barora
HSC (Science) 2013 ram sharan roy Bihar 69.6
college
Bachelor of 2018 nitm Rajiv Gandhi SGPA I 6.5 Full-Time
Engineering in Proudyogik SGPA II 6
Mechanical Vishwavidalay
a SGPA III 6.62
SGPA 6.94
IV
SGPA V
CGPA 6.5
Equivale 65.0
nt
Percent

Affidavit and Score

Affidavit Uploaded :
CAT Percentile :
XAT Percentile :
CMAT Percentile : 90.75
GMAT Score :

Work
Experience
No work experience mentioned.
Family Details
Father's Detail Mother's Detail
Name : Santosh Kumar Roy Name : Sharmila Devi
Email : Email :
Mob No : 8002085141 Mob No : 8298112814
Occupation : service Occupation : housewife
Organization : bharat coking coal limited Organization :
Designation : machinist Designation :
Residential : Residential :
Number Number
Office Number : Office Number :
Office Address : bccl area-1 muraidih dist.- Office Address :
dhanbad, jharkhand
State : jharkhand State
Pincode : 828306 Pincode
Annual Income in : 10 Annual Income in :
Lakhs (Rs) Lakhs (Rs)

Guardian Details
Local Guardian Name : santosh kumar roy
Local Guardian Mobile No : 8002085141
Local Guardian Address : q.no- 706 new colony muraidih p.o.- pochari dist.- dhanbad, jharkhand

Medical History
Details of any major ailments (which requires hospitalization and / or continuous treatment) :
Present status of ailment (if any) :
Physical Disability (if any) :
Declaration
I have uploaded the following self-certified documents and submitted at the time of registration:

i) Hard copy of mail which I have received for joining at IMT.

ii) Original Test Score Card (CAT/XAT/GMAT/CMAT)
iii) X Standard (SSC) Marks-sheet and Passing Certificate
iv) XII Standard (HSC) Marks-sheet and Passing Certificate
v) Graduation Mark sheet (if completed)/ if not, will submit by September 30, 2019 with minimum 50% of marks.
Failing which institute may cancel my admission.
vi) Work Experience Certificate (s) / Relieving Letter of last employer.
vii) AICTE Affidavit by Student and Parents.
viii) Medical certificate (if any).
ix) Gap certificate (if any).

I hereby declare that the information furnished above are true to the best of my knowledge. In
case any of the above information is found incorrect, the Institute can take appropriate punitive
action against me as it deems fit.

Date __________ Place __________

nishant kumar

For Office Use only

Verified by APO_________________________