ANNEXURE-1

INDIAN INSTITUTE OF MANAGEMENT CALCUTTA INDIAN INSTITUTE OF TECHNOLOGY KANPUR INDIAN INSTITUTE OF TECHNOLOGY MADRAS Application Form for

Affix recent Colour Photograph 35 mm x 45 mm

Admission to
Post Graduate Program for ExecutivesVisionary Leadership in Manufacturing 2013-2014

Test/InterviewisplannedtobeheldinKolkata.However,wearealsoconsideringadditional testcentersincasesufficientnumbersofapplicantsoptforit. Pleaseindicateyourorderofpreferenceas(1),(2),(3),(4) Kolkata

Gurgaon

Mumbai Chennai

1. Personal Information Family Name Middle Name .. First Name. (As recorded in the school leaving certificate) Date of Birth (DD/MM/YY):_____/______/______ (as recorded in the school leaving certificate or birth certificate) Nationality: Gender: Marital Status: Parents Name : Indian Male Single Other Female Married Father _________________________________ Mother _________________________________ Husbands/Wifes Name ____________________________________ (in case of married applicant) Applicants Passport No. ___________ Valid Upto: ___________

Date of Issue: ___________ Place of Issue _______ (Since study visit abroad is compulsory part of the program, attested copy of the passport must be submitted with the application before registration) Permanent Address Address____________________________________________________________________ City_____________________ Postal Code_______________State________________ _ Fax_________________Mobile________________________ Phone___________________ Email 1_______________________________ Email 2______________________________

Current Address (at which correspondence to be sent) Address____________________________________________________________________ City_____________________ Postal Code_______________State________________ _ Fax_________________Mobile________________________ Phone___________________ Email 1_______________________________ Email 2______________________________ 2. Application Processing Fee (non refundable) Rs.2,500/- by Bankers Cheque/Demand Draft drawn in favour of Indian Institute of Management Calcutta payable at Kolkata enclosed. Particulars of D.D/ bankers enclosed DD/Bankers Cheque No _______________________________Date____________________ Issuing Bank Name/Branch_____________________________________________________ (Please write your name at the back of the Bankers Cheque /Demand Draft) 3. Funding of Program: Please give details of how you propose to pay for the course: Company sponsorship / Bank Loan / Own sources / Others (please specify)_________ If sponsored, please attach a letter from the Company giving details of terms and conditions and extent of sponsorship.

4. Category of Application (please stick the appropriate box). (a) Self Sponsored will resign (b) Self Sponsored- - on Study Leave (c) Sponsored (a) Self Sponsored will resign In case of candidates who plan to resign from service, letter of resignation and release from last employer is to be produced in original on or before registration. (b) Self Sponsored on Study Leave Candidate in service applying under this category must submit with application form, attested copy of the application for study leave bearing signature and seal of receipt of the employer along with letter or endorsement of consent of the employer on the application. (c) Sponsored Candidates applying under Sponsored category must submit letter of intent of sponsorship issued by the employer with the application form and submit attested copy of letter/bond from the employer containing the details of terms & conditions and extent of sponsorship on or before registration.

5. Academic Qualifications a. Secondary (Class 10 or equivalent) School Examination. Please attach self-attested copies of transcripts of examination passed. Institute Board Examination passed Year of passing GPA /percentage Class/ Division/Rank

b. Higher Secondary (Class 12 or equivalent) School Examination. Please attach self attested copies of transcripts of examination passed . Institute Board Examination Year GPA Class/ passed /percentage Division/Rank of passing

c. Engineering Degree. Please attach self attested copies of transcripts of examinations passed. Institute University Date From To Percentage
1 Year
2
nd

Rank/ Division

Branch

st

Year

rd th

Year

4 Year

Aggregate
of 1-4 years

Whether you have passed any subject in more than one attempt?

Yes/No

If Yes, please indicate the subjects____________________________________________ d. Masters Degree or other Post Graduate Degree. Please attach Xerox copies of transcripts of examinations passed. Institute University Date From Percentage To Specialisation Major Minor

e. Additional Masters Degree or other Post Graduate Degree. Please attach self attested copies of transcripts of examinations passed. Institute University Date From To Percentage Specialisation Major Minor

6. Test Scores (If Available) (A) GMAT (Graduate Management Admissions Test) Score: Registration Number_________________________ Test Date________________________ Verbal Score________________________________Percentile________________________ Quantitative Score___________________________Percentile________________________ Total Score________________________________Percentile________________________ Analytical Writing Score_____________________Percentile________________________ (B) GRE (Graduate Record Examinations) Score: Registration Number________________________Test Date_________________________ Verbal Reasoning Score_____________________Percentile_________________________ Quantitative Reasoning Score________________Percentile__________________________ Total Score_______________________________Percentile__________________________ 7. Work Experience (only full time experience to be considered)

a. Aggregate work experience (in completed years and months as on 28th February, 2013.) _______Years_______Months (attach supporting documents) b. Current Employer Name of Company____________________________________________________________ Address_____________________________________________________________________ City____________Postal Code__________State & Country__________ Fax : ____________ Tel_____________________Company website________________Email________________ Main field of activity__________________________________________________________ Number of employees______________________Annual Sales (in INR)_________________

c. Your current responsibilities Job Title_________________________ Number of years in this position________________ Brief description of business____________________________________________________ Responsibilities: Please give a description of your exact job, including nature of work, major responsibilities (if possible, draw an organization chart and give your job description. Use extra sheet if necessary)

Number of people managed____________________ Assets under your management_________________ d. Contact details of current employer:

Name_________________________________Designation___________________________ Postal Address_______________________________________________________________ Email________________ Phone____________________ Fax _________________________ Mobile__________________________ e. Is your employee prepared to provide you with facilities/access to undertake in-company project during the final months of program? Yes/No/to be confirmed f. Career Summary

Please provide chronological details of your work experience in the table below. List your present position first.
Name of Organization Joining Date Leaving Date Duration Designation/ responsibility Reasons for leaving

g. Last Pay : Please enclose copy of the last pay certificate for the month preceding the month of submission of application. Basic DA Others (Specify details) Gross

h. Give detailed descriptions of three activities you performed in your workplace in the last five years which will help us assess your abilities and strengths. Use extra sheets if necessary.

i. Narrate an important/unusual incident of your life when you had to face a very
demanding/challenging situation. How did you overcome the situation? What lessons did you learn from this incident? Use extra sheets if necessary.

10. Activities and interests: Please list in your order of importance, any extra-curricular activities in which you are/have been involved (sports, community activities, hobbies etc) Activity Duration Level of involvement/ achievements

11. Whether submitted Letter of Recommendation from employer in prescribed form in separately sealed envelope along with application material by the application submission deadline date. Yes No

The above information, as submitted, is to the best of my knowledge and belief.

Place: Date:

(Signature in full by the Applicant)

Send the duly filled in application form, recommendation letter, required documents, if any and application processing fee in the form of Demand Draft/Bankers Cheque drawn in favour of Indian Institute of Management Calcutta payable at Kolkata to the following address by 30th November, 2012, Friday. Chairman, PGPEX-VLM PGPEX-VLM Office Indian Institute of Management Calcutta D H Road, Joka Kolkata 700104

LETTER OF RECOMMENDATION Note: 1. The form should be submitted by applicant in sealed envelope 2. The letter has to be sealed by referee before handing over to applicant Section to be completed by applicant Name______________________________Signature_____________________________ Section to be completed by referee Based on your experience, rate the applicant in the following areas vis--vis persons of similar academic and professional standing: Truly Exceptional Very Good Below Unable exceptional top 10% good top middle average to judge top 2% 50% lower 25% 25%
Initiative Flexibility Maturity compared to peers Oral communication skills Written communication skills Ability to work with others Ability to accept constructive feedback and learn from it Ability to understand others viewpoints Ability to complete work in time Self confidence Leadership

Please include any material you believe is relevant. How long have you known the applicant and in what capacity: Any other comments:

Name & Designation : Telephone No. Fax No. E-mail ID : : : :

Signature with Office Seal