Indian Institute of Management Ahmedabad (IIMA)

APPLICATION FORM

ePGP 2017-19IIMA’s e-Mode PGP

Lead ID: ......................................... Prospect ID: ............................................

First Name: ................................................................................................................

Middle Name: ............................................................................................................

Last Name: ................................................................................................................

Enroll Center: ............................................................................................................

Batch Code: ..............................................................................................................

Study Center: ............................................................................................................

Email Id: ....................................................................................................................

Mobile No.: ................................................................................................................

Personal Details

Father’s/Mother’s/Husband’s Name: .........................................................................

Date of Birth:

Alternate Email: .........................................................................................................

Nationality: ................................................................................................................

Correspondence Address

House No.: ................................................................................................................

Street/Block: ..............................................................................................................

Locality: .....................................................................................................................

State: .........................................................................................................................

City: ...........................................................................................................................

Zip code: ...................................................................................................................

D D M M Y Y Y Y

Education History (Highest First)

Name of Exam

Degree Awarded

Year of Passing Division Marks (%) CGPA/CPIInstitute/University

Type of Admission Test: (Tick One)

If you are appearing for IAT, preference for test centers:

GMAT

Option(1)

Option(2)

Option(3)

CAT

IAT

Year

Year

Score

Score

Work History (Current Employment First)

Company Name

Designation Total Exp.Job

Description

Gross Monthly Emoluments in INR/US$

Exp. From Exp. To

Statement of purpose: (Why you want to enroll for ePGP and how it will benefit your career?)

Any additional information about yourself, you would like to share:

‘e’ stands for Electronic Mode (Interactive Onsite Learning)