Post Graduate Program for Executives for Visionary Leadership in Manufacturing

PGPEX-VLM : Admissions (2017-18)

INDIAN INSTITUTE OF MANAGEMENT INDIAN INSTITUTE OF TECHNOLOGY INDIAN INSTITUTE OF TECHNOLOGY

CALCUTTA KANPUR MADRAS

1. Personal Information

Name Affix self-attested

First name Middle name Last name recent colour
photograph
/ /
Gender Date of Birth
Male Female dd/mm/yyyy
Parents
Father Mother
Name
Nationality Place of Birth
City/Town Country
Passport Number / /
Date of Expiry
Place of Issue dd/mm/yyyy
(Study visit abroad is compulsory part of the program. Attested copy of the passport must be submitted with the application.)

Other Citizenship, if any

Country of Current
Country of Permanent Residence
Residence
Mother Tongue
Other Languages known
Marital Status Single Married Others
2. Contact Information

Company

Address
Present Business
Address
City Postal Code

State Country

Phone Fax

Address

Permanent Address City Postal Code

State Country

Phone Fax

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Preferred
Communication Present Business Address Permanent Address Address given below
Address

Address

City Postal code

State Country
Phone Fax

Email Address Alternate Email Address

Preferred Phone
Alternate Phone Number
Number
3. Application Fees

INR 2,500/- (Non refundable) for Indian nationals and USD 100/- for NRI / Foreign Nationals/ Applications sent from outside
India. Demand Draft should be drawn in favor of Indian Institute of Technology Kanpur, payable at Kanpur, India.

/ /
Demand Draft No. Date
dd/mm/yyyy

Bank details

4. Funding of Program

The course fee for the PGPEX program is Rs. 9,00,000/- (Rupees nine lakhs only, subject to revision) payable in four installments.
Furthermore Rs. 20,000/- (Rupees twenty thousand) has to be paid as refundable caution deposit at the time of registration.
*Education loans are available at competitive rates from leading banks subject to certain pre-conditions.

How you propose to pay for this

course ?
Bank Own fund Company sponsorship / Other sources( Please specify)

How did you come to know about

PGPEX-VLM ?

Are you a re-applicant ? Year of previous application

No Yes

5. Category of Application

Self Sponsored will resign Self Sponsored on Study Leave Sponsored

(a) Self Sponsored will resign: In case of candidates who plan to resign from service, letter of resignation and release from
employer is to be produced in original on or before registration.
(b) Self Sponsored- on Study Leave: Candidates in service applying under this category must submit with application form,
attested copy of the application for study leave bearing signature and seal 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 and conditions
and extent of sponsorship on or before registration.

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 6. Academic Qualifications
Please attach attested/notarized copies of transcripts of all examinations passed. Use extra sheets, if necessary.
Exam/ Dates attended
Institution name with CGPA/
Degree Rank/Division
full address (Major) From To Year of passing Percentage

Secondary / / / /
(Class 10 or
equivalent)

Higher / / / /
Secondary
(Class 12 or
equivalent)

/ / / /
Engineering
Degree

Whether you have passed any subjects in more than one

YES NO
attempt ?

If YES, please mention the subjects

Masters / / / /
Degree / Post
Graduate
Degree

Whether you have passed any subjects in more than one

YES NO
attempt ?

If YES, please mention the subjects

7. Test Scores

*GMAT - Graduate Management Admissions Test (taken within last 36 months)

Registration number
GMAT / /
Test date
dd/mm/yyyy

Verbal score Percentile

Graduate
Management Quantitative score Percentile
Admission Test
Overall score Percentile

AWA score Percentile

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 *GRE - Graduate Record Examination (taken within last 36 months)

Registration number
/ /
Test date
GRE dd/mm/yyyy
Graduate Record
Examination Verbal Reasoning Score Percentile

Quantitative Score Percentile

Overall score Percentile

AWA score Percentile

8. Work Experience
Please attach attested/notarized copies of supporting documents. Use extra sheets, if necessary.
Aggregate full time work-
experience
(In completed years and months as on Years Months
28th February, 2017)
Managerial work-experience
(In completed years and months out of
aggregate work-experience given above) Years Months

Company Name
Industry
Address
Postal Code
State Country

Your current employer Tel. Fax

E-Mail
Website
Total employees
Annual sales (INR)

Main field of Activity

Job title / Designation

Area of expertise

No. of years in this position

Your current job
No. of reportees

Assets under your

arrangement

Name , Designation, Postal

Address, Email and Phone
details
Your direct supervisor

To whom does he/she report

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Last Pay Details
Please enclose copy of the last pay certificate for the month preceding the month of submission of application.

Basic D.A. Total

Other Information

Is your employer prepared to provide you with

facilities/access to undertake in-company project during
final months of the program ? Yes No To be confirmed

Your Job Description

Please give a description of your exact job, including nature of work, major responsibilities etc. (If possible, draw an organization chart and give your job
description. Use extra sheets, if necessary).

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 9. Career Summary
Please provide chronological details of your work experience below. List your present position first. Kindly note that you will be required to submit a certificate
of employment from your last employer in case you are granted admission. Use extra sheets, if necessary.

Name of organization
Industry
Complete address
including contact
numbers
Website address
Starting date / /
1
Ending date / /
Last designation
Functional area of work
Last drawn salary
International exposure
(if any)
Reason for leaving
Name of organization
Industry
Complete address
including contact
numbers
Website address
Starting date / /
2
Ending date / /
Last designation
Functional area of work
Last drawn salary
International exposure
(if any)
Reason for leaving
Name of organization
Industry
Complete address
including contact
numbers
Website address
Starting date / /
3
Ending date / /
Last designation
Functional area of work
Last drawn salary
International exposure
(if any)
Reason for leaving
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 Name of organization
Industry
Complete address
including contact
numbers
Website address
Starting date / /
Ending date / /
4 Last designation
Functional area of work
Last drawn salary
International exposure
(if any)
Reason for leaving
Name of organization
Industry
Complete address
including contact
numbers
Website address
Starting date / /
5
Ending date / /
Last designation
Functional area of work
Last drawn salary
International exposure
(if any)
Reason for leaving
10. Activities and Interests
Please list, in order of importance to you, any extra-curricular activities in which you are/have been involved (i.e., sports, politics, community activities,
hobbies etc.) Use extra sheets, if necessary.

Duration
Activity/Interest Level of involvement / achievements, etc.
From To

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 11. Statement of Purpose

The Statement of Purpose and Objectives for joining PGPEX-VLM - is your opportunity to inform the faculty reviewers of your qualifications, motivation, and
potential to make a contribution to the field of manufacturing. Use extra sheet, if necessary.

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 12. Essay

Describe three major activities you performed in your workplace in the last five years which will help us assess your abilities and strengths. Write a detailed
essay on the most important activity performed. Use extra sheet, if necessary.

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 13. References

Two letters of recommendation in the format given must be sent to the Institute within the application deadline date. The
recommenders should separately seal the envelopes and sign on the flap.
Please list below the name and complete address of each person to whom you have given a recommendation form. Each
should be well acquainted with your intellectual abilities, academic performance, and personal character. At least one of
these two letters should be by someone from industry who is familiar with your professional achievements.

Recommender - 1
Name

Complete address

Organization
Relationship with applicant
Email
Mobile
Phone
Fax
Recommender - 2
Name

Complete address

Organization
Relationship with applicant
Email
Mobile
Phone
Fax

Recommender may send the scanned copy of the Recommendation Letter duly signed by him/her via e-mail directly to
[email protected]

Note: Please note that the Institute will not be responsible if the recommendation letter is not received within the due date
(either hard copy or e-mail). In the absence of the recommendation letter within due date, the application is liable to be
rejected.

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 13. (a) Letter of Recommendation - 1
This section is to be completed by the Recommender.
How long have you known
the applicant ?
In what capacity have you
known the applicant ?

Based on your experience, rate the applicant in the following areas vis--vis persons of similar academic and
professional standing.
Truly Below
Exceptional Very good Good
exceptional average Cant say
(Top 10%) (Top 25%) (Middle 50%)
(Top 2%) (Lower 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 the same

Ability to understand others

viewpoints

Ability to finish work in time

Self confidence

Leadership

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Please fill out the following information and / or write a separate Letter of Recommendation if necessary.

Please describe the particular talents, strengths, and weaknesses of the applicant. If you have worked with the applicant on any
type of special project, please give an evaluation of his/her performance. Please indicate any favorable or unfavorable indications
of the applicants leadership potential and his/her ability to do work independently. Please include any additional information that
you believe is relevant. Use extra sheets, if necessary.

Signature with
Name : Date :
office seal :

Designation : Telephone No.: Fax No. :

E-Mail

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 13. (b) Letter of Recommendation - 2
This section is to be completed by the Recommender.
How long have you known
the applicant ?
In what capacity have you
known the applicant ?

Based on your experience, rate the applicant in the following areas vis--vis persons of similar academic and
professional standing.
Truly Below
Exceptional Very good Good
exceptional average Cant say
(Top 10%) (Top 25%) (Middle 50%)
(Top 2%) (Lower 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 the same

Ability to understand others

viewpoints

Ability to finish work in time

Self confidence

Leadership

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Please fill out the following information and / or write a separate Letter of Recommendation if necessary.

Please describe the particular talents, strengths, and weaknesses of the applicant. If you have worked with the applicant on any
type of special project, please give an evaluation of his/her performance. Please indicate any favorable or unfavorable indications
of the applicants leadership potential and his/her ability to do work independently. Please include any additional information that
you believe is relevant. Use extra sheets, if necessary.

Signature with
Name : Date :
office seal :
Telephone
Designation : Fax No. :
No.:
Email id :

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 14. Application Submission

Please send the completely filled in application form along with GMAT/GRE score, two recommendation letters, required
documents if any, and application fee, in the form of Demand Draft drawn in favor of Indian Institute of Technology, Kanpur
payable at Kanpur, India, to the following address:

VLFM Office
Department of Industrial & Management Engineering
Indian Institute of Technology Kanpur
Kanpur, Uttar Pradesh
208016
India

E-Mail: [email protected]
Tel : +91-512-2596590 / 2597376

The completed application form should reach Indian Institute of Technology, Kanpur by 07 December, 2016

15. Disclaimer and Signature

I certify that the information provided here is true and complete to the best of my knowledge. If this application leads to
an offer of admission, I understand that false or misleading information may result in the cancellation of my
candidature.

Signature in full by the Applicant

Date Place

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