First Name* Middle Name* Last Name* Mr. Miss. Mrs.

Date of Birth* dd 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / mm January February March April May June July August September October November December / yyyy 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Gender* Male Female

Category* -- Select -- General OBC SC ST Others Marital Status* Unmarried Married

Passport No. PAN No.

Permanent Address * City* State* -- Select -- Andaman & Nicobar Andhra Pradesh Arunachal Pradesh Assam Bihar Chandigarh Chhattisgarh Daman & Diu Delhi Goa Gujarat Haryana Himachal Pradesh Jammu & Kashmir Jharkhand Karnataka Kerala Madhya Pradesh Maharashtra Manipur Meghalaya Mizoram Nagaland Orissa Pondicherry Punjab Rajasthan Sikkim Tamil Nadu Tripura Uttar Pradesh Uttarakhand West Bengal Pin* (enter digits only) Mobile* (enter digits only) Landline / Fax No. STD Code Number (enter digits only) Email*

Present Address      Same as above
City*		State*	-- Select -- Andaman & Nicobar Andhra Pradesh Arunachal Pradesh Assam Bihar Chandigarh Chhattisgarh Daman & Diu Delhi Goa Gujarat Haryana Himachal Pradesh Jammu & Kashmir Jharkhand Karnataka Kerala Madhya Pradesh Maharashtra Manipur Meghalaya Mizoram Nagaland Orissa Pondicherry Punjab Rajasthan Sikkim Tamil Nadu Tripura Uttar Pradesh Uttarakhand West Bengal	Pin*	(enter digits only)
Mobile*	(enter digits only)	Landline / Fax No.	STD Code Number (enter digits only)

Academic Qualification
Examination	University / Institution	Year of Passing (YYYY)	Faculty of Studies	Division / Distinction	% of Marks Obtained	Honour / Scholarship / Prizes Won
10+2 *
Graduation*
Post-graduation

Parent's / Guardian's/Husband'S Name
	Father *	Mother *
Occupation *	-- Select -- Business Service Self - Employed Retired Agriculture Others	-- Select -- Business Service Self - Employed Retired Agriculture Others

IMPORTANT REFERENCES:
Name*
Address*
	Mobile	(enter digits only)
Details of Work Experience:
Employer
Duration
	Position Held
	Last Salary Drawn
If Appeared for any Entrance:
Name of Examination
Month/Year
	Score
	Name of parents who will stand as co-applicant	Father      Mother
Name of parent who will stand as surety for the loan

Other Interests & Achievements
Why do you want to join MBA/PGDITM/PGCM at NDIMS?*
Will you require Hostel accommodation? *	-- Select -- Yes No

I declare that the information furnished above is correct and complete. I accept that providing of incorrect information or withholding of relevant information may disqualify me for admission. I agree to abide by the rules and regulations of the Institute.

I accept the Terms and Conditions