APPLICATION FORM For 12th Batch ( )

Transcription

1 U Index Number (for official use only) APPLICATION FORM For 12th Batch ( ) Two-year full time residential MBA(RM) Programme KIIT School of Rural Management KIIT University, Bhubaneswar Please fill up all the sections below in your ownhandwriting. (Incomplete or illegible application forms are liable to be rejected) Paste your recent passport size photograph here (do NOT staple) SECTION A: Centre & Scores 1. Mark your order of preference(1 for first preference to 5 for last preference) for Centre for Group Discussion & Personal Interview (GD & PI) Bangalore Bhubaneswa r Delhi Kolkata Mumbai jamshedpur 2. Select the entrance test score you will be submiting CAT CMAT XAT MAT GM AT KIITEE MGT ID / Regn. No / Roll No Composite Score / Percentile... NOTE:- The above entrance tests taken from 1st April, 2017 onwards will only be considered SECTION B: Key Personal Information (Please leave one boxblank between two words) 3. Full Name (in block letters) 4. Father s Name 5. Mother s Name 6. Date of Birth D D M M Y Y Y Y 7. Gender (Tick whichever is applicable ) Male Female 8. Marital Status. 9. Category (Tick whichever is applicable ) GENERAL OBC SC ST 10. Nationality 11. Religion

2 12. Mother Tongue 13. Address for Correspondence (in block letters) PINCODE 14. Permanent Address (in block letters) PINCODE 15. Address Tel. No. (With STD Code). Mobile 16. Occupation of Parents Father Mother 17. Total Annual Household Income (gross) Do you plan to avail a study loan for the course Yes No 19. In case of emergency, we can contact Mr./Ms./Mrs Landline Phone Mobile Relationship with you 20. Whether physically challenged Yes No Details (if the answer above is Yes ). 21. Blood Group 22. If you have participated in any sports/games at State/National level, give details 23. Details of Application Fee (Rs. 1250/-): Drawee Bank. DD No. Date..

3 SECTION C: Education & Experience 24. Educational Details: Examination i. Matriculation/ Secondary School Examination ii. +2/Higher Secondary/ Equivalent iii. Degree Board/ University College/ Institute Year of Passing Stream Class % of Marks* iv. Please indicate if you have appeared in any Degree exam. and result not declared iv. Specify Post Graduate Degree, if any * % of marks in aggregate, including optional. 25. Work Experience (write latest experience first; attach separate sheet, if necessary) Organization Duration Designation Responsibilities From To (Month/Year) (Month/Year) SECTION D: Other Information Please think very carefully before answering the question below. Ensure that each answer is AT LEAST 60 words long. 26. How do you expect MBA(RM) to benefit you?

4 27. Give an example of something that you did well. Why do you think you succeeded? 28. Give an example of something you have failed in. Why did you fail? Declaration I certify that the information furnished in this application is true to the best of my knowledge and belief. My application may be rejected and admission cancelled if any information provided herein is found to be incorrect at any time during or after the admission. Signature of the candidate in full.. Place Date Enclose a copy of the following documents and tick appropriate boxes Total documents attached 1. High School Certificate and Mark sheet. 7. KIITEE MGT/ CAT/ /HSC Certificate and Mark sheet XAT/CMAT Score card. 3. Graduation (B.A, B.Com, B.Sc, Engineering 8. College Leaving Certificate etc.)certificate and Mark sheet 9. Migration Certificate 4. Caste certificate, if applicable 10. Conduct Certificate 5. Physically challenged certificate, 11. Any other, Please Specify if applicable 6. Sports / Extra-curricular participation certificate, if applicable

5 UFOR OFFICIAL USE The candidate has been selected / waitlisted in the interview held on... for MBA(RM) Programme. Payment Details Fee Due Date Payment Date Confirmation Amount DD Number DD Date Bank Admission (First Installment) Admission Permitted / Not Permitted Admission Officer Coordinator, Admissions Director, KSRM Completed application along with enclosures should reach: Admissions Coordinator KIIT School of Rural Management(KSRM), Krishna Campus -7 KIIT University, Bhubaneswar , Odisha, India Phone: Mobile: , , HUadmission@ksrm.ac.in UH, web site: HUwww.ksrm.ac.in U