भारतीय प्रबंध Indian Institute of Management

Prabandh Nagar, Off Sitapur Road,

संस्थान Lucknow – 226 013 (U.P.) India

प्रबंध नगर, ऑफ सीतापुर रोड,

लखनऊ-226 013 (भारत)

Executive Programme in Strategic Operations Management & Supply Chain

Analytics (EPSOMSCA)
Programme Duration: Feb 17, 2024- Dec, 2024
Programme Directors: Prof. Rakesh V. and Prof. Yash Daultani

REGISTRATION FORM
(FILL IN CAPITAL LETTERS)

1. NAME (FOR CERTIFICATE) : MR./MS./DR.

2. GENDER : MALE FEMALE

3. DATE OF BIRTH : _

4. DESIGNATION : _

5. NAME & ADDRESS OF : _

ORGANIZATION

PHONE (O): _ FAX:

MOBILE NO: _

E‐MAIL:

ALTERNATE E‐MAIL :

6. RESIDENTIAL ADDRESS : _

PHONE (R): _

DATE:

SIGNATURE
 Management Development Programme
Indian Institute of Management Lucknow
Executive Programme in Strategic Operations Management & Supply Chain Analytics (Batch 4)
Feb 17, 2024- Dec, 2024
Acceptance of Terms and Conditions

This is to state that I have read and agreed to the terms and conditions in the EPSOMSCA-04 program
Student Manual, Program Brochure and copy of the Sample Certificate.

I hereby give an undertaking that I will abide by the rules and regulation of the student manual. I understand
that I shall be liable for suitable disciplinary action in case of any violation of the student manual guidelines as
well as the Institute’s rules and regulation. I further undertake to complete the program in its true spirit.

I, do hereby solemnly pledge that I shall, in thought, word and deed, endeavor to be worthy of the certificate
that will be conferred on me by the Indian Institute of Management Lucknow after completion of the course.

Thank you,

My contact details are as under.

Name: -------------------------------------
Correspondence Address: -------------------------------------
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Mobile: -------------------------------------
Email: -------------------------------------

Signature of Student

Date: - Place: