BIMTECHBIRLA INSTITUTEOF MANAGEMENT TECHNOLOGYExC<!n.""" with V.lu".
APPLICATION FORM FOR ADMISSION-2014PGDM PROGRAMMES FOR GREATER NaiDA CAMPUS
(Important Note: - Use Ball Point Pen to fill the application in CAPITAL LETTERS)
Application Form No. (For Office use only) .
Applicants last name .
PASTE HEREFIRMLY YOUR
RECENT COLORPHOTOGRAPH
Applicants first name .
Applicants middle name .
Date of Birth (dd/mm/yyyy) .
Category DSC 0 ST 0 OBC (Non-Creamy) 0 General
! Is Physically Handicapped 0 Yes 0 No Is Economicaliy Backward DYes D No
Gender 0Male 0Female Nationality Domicile State .
Address Line 1 .
Address Line 2 .
Address Line 3 : City .
,Country.............................. State . Pin Code: .
Telephone STD Code Telephone Number Mobile No .
E-mail id .......................................................•... Alternate E-mail id .
Father's Name................ Mother's Name .
Father's Occupation Mother's Occupation .
Total Annual Income (of Both the Parents) .
Work Experience from to Work Exp. in Months .
Name of the Organization Work Experience Sector .
Company turnover (Min. Rs. 50 Crore)................................. Designation .
Eligible Role 0 Executive 0 Supervisory 0 Managerial D Annual Salary Package (Min. Rs. 1.8 Lakh) .
SSC Board .
SSC Percentage (all subjects) SSC Mode (eg. Regular/PrivatelDistance) .
HSC Board HSC Discipline (eg.-Science/Commerce/Arts) .
HSC Percentage (all subjects) HSC Mode (eg. Regular/PrivatelDistance) .
Birla Institute of Management Technology, Plot No.5, Knowledge Park II, Greater Noida, 201 306, IndiaTel: +91-120-2323001-10, Toll Free NO.-180018001111, Mobile:-9718444466
Website: www.bimtech.ac.in. Email: [email protected] 1 of 3
~ BIMTECH• BIRLA INSTITUTE
ExreliencewithV.lu.. OF MANAGEMENT TECHNOLOGY
Whether Bachelors Degree Completed DAre there any paper(s) uncleared / to be repeated
Yes D No Year of Passing .
DYes D No
Bachelors Degree Percentage (If Completed) (If Not Completed - Aggregate till last year) .
Bachelors Degree Name (e.g. BA, B,Sc, B.Com. etc.) .
Bachelors Degree Mode (eg. RegularlDistance Learning/Correspondence) .
Bachelors Degree Type of University (eg. Central/State/Deemed/NITIIiTlAny Other) .
Bachelors Degree University State (eg. UP/MP/KeralalWest Bengal etc) .
Bachelors Degree University Name .
Bachelors Degree Institute/College Name .
1Do you wish to apply for BIMTECH scholarship? DYes D No
TEST DETAILS REGISTRATION NO PERCENTILE.CAT-2013
XAT-2014
MAT- (Sep/Dec-2013 or Feb-2014)
CMAT- (Sep-2013/Feb-2014)
GMAT - (2013-14)
Note: (1) For CMA T Candidates only to enter their CMAT Score (out of 400)(2) For eligibility criteria, please visit http://bimtech.ac.in/admissions/fee-structure/
Note: You can tick C-J) any two candidate categories in order of preference
Preference-1 Preference-2S.No. Candidate Category
(tick only one) (tick only one)
1 Merit
2 Corporate Sponsored
3 NRI Sponsored
4 NRI
5 International Student
Birla Institute of Management Technology, Plot No.5, Knowledge Park II, Greater Noida, 201 306, IndiaTel: +91-120-2323001-10, Toll Free NO.-180018001111, Mobile:-9718444466
Website: www.bimtech.ac.in.Ernail:[email protected] 2 of 3
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~ BIMTECH• BIRLA INSTITUTE
Ex«!II.ncewlthV~lu... OF MANAGEMENT TECHNOLOGY
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Note: You can ..tick ('-.1) any two programs preferences in order of preference
Preference-1 Preference-2S.No. Program Preference
(tick only one) (tick only one)
1 PGDM
2 PGDM (International Business)
3 PGDM (Insurance Business Management)
4 PGDM (Retail Management)
5 PGDM (Sustainable Development Practices)
Note: You can tick (,J) anyone GO/PI preference -,. .~
City for attending GO/PIPreference
D Bhubaneswar D Greater Noida
How did you come to know about BIMTECH? .(e.g. News Paper AdvertisementlEducational PortallCoaching Institute/Alumni/StudentlTV Commercial etc )
r Demand Draft Details: DO No DO Date: .
Drawn on Bank: Branch: .
Demand Draft for Rs. 1050/- drawn in favour of "BIRLA INSTITUTE OF MANAGEMENT TECHNOLOGY", payable at Greater Noida
INoidalNew Delhi. (Only accepted with the application form downloaded from www.bimtech.ac.in)
DECLARATION BY THE CANDIDATE
I certify that I satisfy the eligibility requirements of the programmes I have applied for and have furnished complete and correct
i information. I also undertake to abide by BIMTECH decisions on all matters regarding the application. In case of any, .discrepancy BIMTECH has full right to cancel my candidature. I undertake to produce the final graduation degree and mark
sheets latest by 31st Oct. 2014, failing which BIMTECH will be free to cancel my admission.
Place: . Signature of the Candidate: .
, Date: 1 1 .
Birla Institute of Management Technology, PlotNo. 5, Knowledge Park II, Greater Noida, 201 306, IndiaTel: +91-120-2323001-10, Toll Free NO.-180018001111, Mobile:-9718444466
Website: www.bimtech.ac.in. Email: [email protected] 3 of 3