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Rajiv Gandhi

Indian Institute of ManagementMayurbhanj Complex, Nongthymmai, Shillong

APPLICATION FORM

FELLOWSHIP PROGRAMME IN MANAGEMENT 2013

Please read the instructions on Fellow Programme as onwww.iimshillong.inbefore filling in the application

form.

AFFIX

PHOTOGRAPH

PERSONAL INFORMATION

1. NAME OF THE CANDIDATE

2. FATHER'S/GUARDIAN NAME

3. PERMANENT ADDRESS

PIN

4. ADDRESS FOR CORRESPONDENCE

PIN

5. E-mail

6. TELEPHONE NO. 7. MOB NO.

8. DATE OF BIRTH 9. GENDER

10. NATIONALITY 11. MARITAL STATUS

Female

Unmarried

http://www.iimshillong.in/http://www.iimshillong.in/http://www.iimshillong.in/http://www.iimshillong.in/

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CATEGORY YOU BELONG TO

Please tick the category you belong to:

General

category

Schedule

Caste

Schedule

Tribe

Other Backward

Class

Persons with

Disability

ELIGIBILITY CRITERIA

CAT

Registration No Test Date

Quantitative Score Percentile

Reasoning Score Percentile

GMAT

Registration No Test Date

Verbal Score Percentile

Quantitative Score Percentile

Overall Score Percentile

AWA

Score Percentile

GRE

Registration No Test Date

Verbal Score Percentile

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Quantitative Score Percentile

AWS

Score Percentile

JRF by UGC

Registration No Year Qualified

Score

GATE

Registration No

Marks

Obtained (Out

of 100)

GATE

Score All India Rank

Total Candidates

Appeared in thesubject

SubjectAppeared

Year Qualified

AREAS OF SPECIALISATION

Tick the area/areas on interest

Economics Marketing Finance & AccountingInformation

Systems

Operations

Management

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ACADEMIC RECORDS

Examination/ Degree/

Diploma/Certificate Board/ Institute Year

Subject

(major/minor)

P.C. (%)

of

marks CGPA

Grade/

Division

(Please enclose mark sheets and certificates of all Research Publications)

RESEARCH WORK/EXPERIENCE

List of Research Publications (enclose copies of all Research Publications)

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

Why have you applied for Fellowship programme (State in 100 words)

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Sl No. Name of the Awards Institution conferring the Award Year

1

2

3

4

5

(Mention only those related to academic and professional achievements)

WORK EXPERIENCE (Starting from the Latest)

Sl No

Organisation/In

stitution Designation

Nature of work/

Responsibilities

Period

From-To

Total

Number

of Months

Monthly

Remunerati

on

Turnover ofthe

Company

(Any)

1

2

3

4

5

6

7

8

9

10

Awards/Medals/Prizes/Scholarships/Certificates/Honours

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Reference 1 (Preferably from Academic Background)

Name

Place of Work

Designation

Relationship withthe Referee

Email ID

Address

Reference 2 (Preferably from Academic Background)

Name

Place of Work

Designation

Relationship with

the Referee

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Email ID

Address

Important Instructions to Remember

A candidate is eligible to submit applications to a maximum of two areas. In such cases, candidates who

choose to apply to two areas are required to submit separate application forms with all supporting documents,

to be sent together.

If short listed, all certificates (originals) should be produced at the time of interview.

The form should be complete in all respects. Incomplete forms will not be considered. Strike out whichever

portion is not applicable.

Please enclosed a Demand draft of Rs.500/- (Rs.250/- for SC/ST Candidates) with the Application Form drawn

in favour of RAJIV GANDHI INDIAN INSTITUTE OF MANAGEMENT, SHILLONG payable at Shillong.

DECLARATION

I hereby certify that all information provided herein is true to the best of my knowledge. I

understand that anything found otherwise at any stage of the process/program will make me

ineligible for the program with immediate effect.

Place: __________________________________

_______________________

Signature of the Applicant

Date: __________________________________

Submit