Five year Integ

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2. Admission
3. In all matt
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TUTE OF MA
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(All information
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ANAGEMENT
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August 2014
ndore: April
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Five year Integrated Programme in Management at IIM Indore - Application 2
(II) ACADEMIC QUALIFICATIONS

A. Provide complete and accurate information on examination marks in all columns.

B. Wherever you have received letter grades or grade points instead of marks, provide equivalent marks and attach a certificate fromcompetent 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:

Standard Name of Board/ University Year Total Max.
Marks/Grade
Total
Marks/Grade
Obtained
% Marks /
Grade
Obtained
Class/
Division/
Rank*
X Std / Secondary/
Equivalent




XI Std / Higher
Secondary/ Equivalent




XII Std / Higher
Secondary / Equivalent




*Please produce certificates/ evidence if grade is mentioned.















Standard From
(Yr.)
To
(Yr.)
Core subjects Marks/ Grade
Obtained
Other subjects Marks/ 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
Five year Integrated Programme in Management at IIM Indore - Application 3
(III) SAT-1 Score details

SAT-1 Score Card
(SAT- 1 scores obtained during J anuary 1, 2013- March 31, 2014 are only valid)
Writing Section Critical Reading Section Mathematics Section Overall

Note: SAT-1 score is mandatory for only those applicants who are unable to meet eligibility in terms of percentage of marks i.e. 60% in
X and/or XII (55% for SC, ST and DA/PWD candidates).

(IV) IPM Test / Interview Centre

Choice of Center for IPM Aptitude Test (May 15, 2014):

Choice of Center for Personal Interview (J une 3-6, 2014), if shortlisted:

(V) SCHOLASTIC ACHIEVEMENTS

Scholastic Achievements: Please list scholastic awards or scholarships conferred on you during your School education at Secondary and Higher Secondary
or Equivalent level in curricular, co-curricular and extracurricular activities at district, state, and national level. You need to produce 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)


























AT Centre Preference
(Bengaluru/ Delhi/ Hyderabad/ Indore/ Kolkata/
Mumbai)
1 2 3



PI Centre Preference
(Bengaluru/ Delhi/ Hyderabad/ Indore/ Kolkata/
Mumbai)
1 2 3



Five year Integrated Programme in Management at IIM Indore - Application 4
(VII) MEDICAL HISTORY
Please state whether you have any existing physical disability or any chronic illness, including mental illness, which could affect your studies at the Institute.


If you have suffered fromany chronic illness, including mental illness, in the past, please provide details below:

Nature of illness When suffered Date of completion of
treatment
Remarks, if any
1.
2.
3.

It is mandatory for all applicants to ensure that they are medically fit for joining the programme and they shall get the medical fitness certificate from
authorised doctor/ hospital preferably fromGovernment Hospitals.

Please note that you are not required to send any medical certificate along with this application form.

(VIII) DECLARATION
I clearly understand that if I amselected, I will be allowed to join the programme only if I satisfy all requirements of the programme including the
submission of a certificate at the time of registration fromPrincipal of my school that except for declaration of results, I have completed all requirements for
obtaining XII Std. / Higher Secondary / Equivalent qualification and that I would have to produce evidence (mark sheet/ certificate) 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 also understand that commitment fee which I may pay at the time of admission are non refundable and no claimwill be made by me or on my behalf for the
same.

I hereby certify that I amfulfilling the eligibility conditions like age and 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 attested copies of all academic certificates / marksheets / certificates fromschool authorities evidencing proof of all
claims made in this application.
Original and attested copy of reservation certificate in case of SC, ST and PWD/DA candidates
A duly signed copy of this application

Place: ______________________


Date: ______________________ _________________________
Signature of the applicant


























Note:- No other document(s) is/are to be attached with the application form except the above mentioned
certificates.
PLEASE READ THIS FORM ONCE AGAIN AND MAKE SURE THAT YOU HAVE COMPLETED ALL
THE DETAILS RELEVANT FOR YOU AND HAVE COMPLIED WITH ALL REQUIREMENTS.
INCOMPLETE APPLICATION ARE LIABLE TO BE REJECTED
Send in your completed application form so as to reach this office latest by April 4, 2014 along with
DD/BC and photocopy of the following: Proof of Date of Birth, 10
th
Marksheet, 12
th
Marsheet (or
provisional certificate) ,NC-OBC / SC / ST Certificate (if applicable), PWD/DA Certificate (if applicable)

To,

The Admissions Office
Indian Institute of Management Indore,
Prabandh Shikhar, Rau-Pithampur Road,
Indore 453556