Five year Integrated Programme in Management at IIM Indore-Interview Form1

INTERVIEW FORM - 2015 (I) PERSONAL DATA Name of the Candidate (Asgiveninthe certificates) Date of BirthAge as on July 31, 2015DDMMYYYYYears Months Gender (Tick appropriate one) MaleFemaleTransgender Category (Tick appropriate one) GeneralNC-OBCSCSTDA/PWD Please tick the relevant box if you suffer from any Physical Disability to the extent of not less then 40% ( as per the Person with Disabilities Act, 1995) Blindness/ Low Vision Hearing Impairment Locomotor Disability/ Cerebral Palsy Please mention the percentage of Disability (%) Note: (Candidates belonging to NC-OBC/SC/ ST/PWD/DA need to submit valid certificate copy with the application) Name of the Parents/ Guardian:Contact number e-Mail Address (Parent/ Guardian) Mailing address (Postal Address): CityStatePIN Phone:Fax: e-Mail Address (Candidate) Indian Institute of Management Indore FIVE YEAR INTEGRATED PROGRAMME IN MANAGEMENT (Commencing in August 2015) Affixyourrecent passportsize colourphotograph hereFive year Integrated Programme in Management at IIM Indore-Interview Form2 (II) ACADEMIC QUALIFICATIONS A.Provide complete and accurate information on examination marks in all columns. B.Whereveryouhavereceivedlettergradesorgradepointsinsteadofmarks,provideequivalentmarksandattachacertificatefromcompetent authority explaining the method of conversion. Where such conversions are not possible, please provide an explanatory note in the additional space provided at the end of this page. The Admission Committee's decision in such cases would be final. Schooling: StandardName of Board/ UniversityYear Total Max. Marks/ Grade Total Marks/Grade Obtained % Marks / GradeObtained Class/ Division/ Rank* XStd/Secondary/ Equivalent XIIStd/Higher Secondary/ Equivalent *Pleaseproduce certificates/evidenceifgradeismentioned. MarksforXandXII class hastobetotal marksasmentionedin your mark sheet, not best five etc.

Standard Year of PassingCore subjectsMarks/ Grade obtained Other subjectsMarks/ Grade obtained No of attempts X Std/ Secondary/ Equivalent XII Std/ Higher Secondary/ Equivalent Space for explanation of letter grades / grade points/ any other relevant information relating to academic qualification (III) SAT-1 Score details SAT Score is compulsary for only those candidates who have applied as an international applicants and didnt appear in the IPM AT 2015 held on 15th May,2015. SAT-1 Score Card (SAT- 1 scores obtained during January 1, 2014- December 31, 2014 are only valid) Writing SectionCritical Reading SectionMathematics SectionOverall Five year Integrated Programme in Management at IIM Indore-Interview Form3 (V) SCHOLASTIC ACHIEVEMENTS ScholasticAchievements:PleaselistscholasticawardsorscholarshipsconferredonyouduringyourSchooleducationatSecondaryandHigher SecondaryorEquivalentlevelincurricular,co-curricularandextracurricularactivitiesatdistrict,state,andnationallevel.Youneedtoproduce certificates in support of your claim. (VI) CAREER PLANS Why do you wish to go in for a management education through five integrated programme? (Limit your response to 100 words) (VII) MEDICAL HISTORY Pleasestatewhetheryouhaveanyexistingphysicaldisabilityoranychronicillness,includingmentalillness,whichcouldaffectyourstudiesatthe Institute. If you have suffered from any chronic illness, including mental illness, in the past, please provide details below: Nature of illnessWhen sufferedDate of completion of treatment Remarks, if any 1. 2. 3. Itismandatoryforallapplicantstoensurethat theyaremedicallyfitforjoiningtheprogrammeandtheyshallgetthemedicalfitness certi ficatefrom authorised doctor/ hospital preferably from Government Hospitals. Five year Integrated Programme in Management at IIM Indore-Interview Form4 (VIII) DECLARATIONIclearlyunderstandthatifIamselected,IwillbeallowedtojointheprogrammeonlyifIsatisfyallrequirementsoftheprogrammeincludingthe submission of a certificate at the time of registration from Principal of my school that except for declaration of results, I have completed all requirements for obtaining XII Std / Higher Secondary/Equivalent qualification and thatIwould have to produce evidence (mark sheet/ cert ificate) of having passed the XII Std/Higher Secondary/Equivalent examination on or before the date of admission. Non-fulfilment of these requirements will automatically result in the cancellation of the provisional admissions offer and no refund of fee will be made. I certify that the particulars given by me in this application are true to the best of my knowledge and belief. I understand that admission granted on the basis of false and/ or misleading information will be ipso facto null and void. I agree to abide by the decision of the institute authorities regarding my selection/ non-selection for the programme. I hereby certify that I am fulfilling the eligibility conditions like Age, Percentage of marks and Reservation Category (If applicable) as per Govt. of India norms.

I undertake to produce the following documents at the time of personal interview, if called for:Original and self-attested copies of all academic certificates / marksheets / certificates from School authorities evidencing proof of all claims made in this application. Original and self-attested copy of reservation certificate in case of SC, ST and PWD/DA candidatesA duly signed copy of this application Place: ______________________ Date: ______________________ _________________________ Signature of the applicant