Serial No - 1520

APPLICATION FORM
2019-2021

Instructions:
1. The application form should be filled in soft copy & save it to take printout.
2. All information asked for should be provided. Incomplete forms will be rejected.
3. In case of paucity of space, you can attach an additional sheet mentioning the item
number.

A. Personal Information (Please fill all the details in capital letters only)

Course Applied for

MBA Hospital and Health Management

i. Name:
First Name Shivani

Middle Name

Last Name .

ii. Gender: iii. Date of Birth iv. Nationality: v. Category

(DD/MM/YYYY) (Gen. / OBC /ST/ SC /Others)

Female 19/05/1996 Indian General

vi. Father's Name:

Mr Arun kumar sinha

Vii. Mother's Name:

Arti sinha

Viii. Name of Guardian (If Father is not alive):

Arun kumar sinha

Guardian/Parent Mobile No:

9431852239

ix. Minority:

No

x. Physically Handicapped (PH):

 Handicapped No Type of Disability % age of Disability
xi. Aadhar no:
550859852210
xii. Address for Correspondence:
hno-6993 east of gorya baba kailash nagar godhna road

City ara State BIHAR Pin Code 802301

Contact No. STD Code Phone no. Cell no.

LandLine 9525298242

Permanent Address
hno-6993 east of gorya baba kailash nagar godhna road

City ara State BIHAR Pin Code 802301

Email ID:
shivanisinha658@gmail.com

B. Application Fee Details:

Amount Rs. 1000 Transction ID 108580391635

C. Academic Performance
In case of grade, authentic conversion formula must be attached.

Post Graduation Stream: B.Sc (zoology Honours)

Maximum Marks: 1500

Aggregate Marks obtained: 988

Aggregate Percentage obtained: 66.00

Please give information about your academic qualifications (start with the last degree down to class X)

Name Name Year % of

S. Max Marks
Education of of of Marks Division Grade
No. Marks Obtained
Examination Board/University* Passing (aggregate)
Write the aggregate percentage of all the years of graduation (Students whose final year result is Awaited should
write the aggregate percentage of previous years).......................

* The degree/course should be recognized by a university in accordance with the Association of Indian
Universities/MCI/AICTE/UGC.

D. Entrance Exam:
S. No. Exam Exam Date Composite Score

* GPAT- Applicable for MBA Pharmaceutical Management

The students who do not have any of the above management aptitude test scores can appear in Management
aptitude test (IIHMR U-MAT) conducted by IIHMR University. Please tick in the Button. if you will like to
appear(IIHMR -U MAT) aptitude test. - No

E. Work Experience(0 Year 0 Month):

Designation/ Year and Month
S. No. Organization
Position Held From/To

Declaration by the Applicant

I hereby certify that the above information provided by me is correct and, I understand
that if the information is found to be incorrect or false, then I will be automatically
debarred from the selection/admission process without any correspondence in this regard.
I also understand that the application/registration/short listing does not guarantee
admission in the University. I accept the process of admission undertaken by the
University and I will abide by the decision taken by the University authorities. I have
checked the information carefully. I will, on admission, adhere to the rules and discipline
of the University. I hold myself responsible for the dues and payment of fees. I confirm
that there is no Criminal case filed against me and will provide the necessary information
as and when required by the University.

Shivani .

Name Signature Date

List of the self attested documents to be attached with the application for admission:-
(To be attached in following sequence)

S. No. List of the documents Tick in the box

 1. Class X Certificate

2. 10+2 certificate showing the subjects passed

Mark sheets of all the semesters/years, degree for the candidates who
have passed the qualifying degree.
3. OR
Mark sheets of the pre-final semesters/years for those who have
appeared at the final year exam for the qualifying degree.

Copy of MAT/CMAT/CAT/ATMA/XAT/GPAT Score

4.
Card/Certificate(s) of work experience.

Affidavits (Format1) on Rs. 10/ - non-judicial stamp paper duly signed

5.
by the student and the Parent/guardian (as per format)

Caste certificate issued by the respective Tehsildar/SDM/DM, in case

6.
the applicant is from any of the reserved categories.

7. Copy of Grade conversion formula. (if applicable)

8. Copy of Physically Handicapped certificate. (if applicable)

9. Copy of Minority certificate. (if applicable)

10. Copy of Internship Certificate. (if applicable)

11. Character certificate by the college/ a gazetted officer

Affidavit by Applicant

I, Shivani .

D/o Mr. Arun kumar sinha

having (name of
been the
admitted institution),
to have

2. I have, in particular, perused clause 3 of the Regulations and am aware as to what constitutes
ragging.

3. I have also, in particular, perused clause 7 and clause 9.1 of the Regulation and am fully aware of
the penal and administrative action that is liable to be taken against me in case I am found guilty of
or abetting ragging, actively or passively, or being part of a conspiracy to promote ragging.

4. I hereby solemnly aver and undertake that

a) I will not indulge in any behavior or act that may be constituted as ragging under clause 3 of the
Regulations.

b) I will not participate in or abet or propagate through any act of commission or omission that may
be constituted as ragging under clause 3 of the Regulations.

5. I hereby affirm that, if found guilty of ragging, I am liable for punishment according to clause 9.1
of the Regulations, without prejudice to any other criminal action that may be taken against me
under any penal law or any law for the time being in force.

6. I hereby declare that I have not been expelled or debarred from admission in any institution in the
country on account of being found guilty of, abetting or being part of a conspiracy to promote,
ragging; and further affirm that, in case the declaration is found to be untrue, I am aware that my
admission is liable to be cancelled.

Declared day month

year
this of of

Name Shivani . Signature

Affidavit by Parent/Guardian

I hereby declare that I am aware of the law in regard to prohibition of ragging and agree to abide by the
punishment meted out to my ward in case the latter is found guilty of ragging and/or abetting ragging.

Arun kumar
Name Signature
sinha
 Place Date

10 marksheet showing the subjects passed

10+2 marksheet showing the subjects passed

Final mark sheet/degree for the candidates who have passed the qualifying degree OR Mark sheet of
the pre-final year for those who have appeared at the final year exam for the qualifying degree

Copy of MAT/CAT/CMAT/ATMA/XAT/GMAT/GPAT* Score Card/Certificate(s) of work

experience.

Affidavits (Format1) on Rs. 10/ - non-judicial stamp paper duly signed by the student and the
Parent/guardian (as per format)

Caste certificate if in case the applicant is from any of the reserved categories as per Government of
Rajasthan reservation policy.

Copy of Grade conversion formula. (if applicable)

Copy of Physically Handicapped certificate. (if applicable)

Copy of Minority certificate. (if applicable)

Copy of Internship Certificate. (if applicable)

Character certificate by the college/ a gazetted officer

Statement of Purpose
Tell us about your journey in life:

My name is Shivani I born in Arrah city in Bihar I come from hardworking and humble family I
have two brothers my father was a bank employee due to which I experienced a lot of transfer from
school to school which made me a tough and determined child and I constantly worked to achieve
the best I can get in my academic got good percentage in 10th class with an outgrowing interest in
Science to PCB in 12th and along with my graduation prepared for Neet but could not succeeded
after graduation the best option for me E with Biology stream is to go in Healthcare management for
that I applied for February mat 2019 and score 650 marks and opted IAS RM for so with the hope to
achieve my life goal in health science

Your three major achievements and why you consider them as your major achievements:

My three major achievements are 1 played for inter school basketball team at district level 2 win
Sanskrit Debate in school 3 qualified Neet two times

Your future goals and purpose in life:

I only wanted to serve people for this I choose to go in the medical line for this I was preparing for
MBBS and doing MBA in hospital management server the same purpose

Why you want to pursue management course from IIHMR U and how this will help in fulfilling your
goals:

I want to do something in Healthcare service for people that is why I prepared for Neet also and
after graduation the best option for me is to do MBA in Healthcare and hospital management

How did you come to know about IIHMR University?:

Through MAT