IBS Application Form

ICFA BUSINESS SCHOOL For 2 year PG Program

Application No: 1 2 21 olos 9

Name of Candidate: Mr./Ms. SA |Ro s |A RANJ|AN MslHI I

(As it appears In the School/College/University certificates Underline Sumame)

PERSONAL DETAILS (Use Capitals Only)

Brth
19 1 o o 14 Blod Group
AOt Moble
3 5 M1s/3 t15G|J
Email" t s h t l a l s l a t l o la lo q e 3 mla l lL Iclom NationalityTrDTAN

Mailing Address
MAND |AlRl eA GT c InA PlAlRA L laalAo a A
ANA klAlLIAHlAlDI LLLLLIL L
&H. e A Ir INALU OolTslHlALII
City
LII tsl6 lolo |1 State Pin

Permanent Address
MlAIRlo lA R 6A loIcltlA IrA& lA gHlA wlAlNae
LAIINlA NLIAHlAlNo al LLLLLLLLLLLLI
lHPAln NlA City
o Oas ktAL State
LLI s l6lolo 1
Pin

2 ACADEMICRECORD
(a)sCHoOL/ JUNIOR COLLEGE
Class Name of the School/ College Year of Passing % of Marks

X
kendiya Vidyalaya Ghavoani
pat na 201 4.
XII
Kandia Vidyalaa hauoanipatna 2019 2-6
2.6

(b)GRADUATION DETAILS (Full-timel Distance)

If Completed
Graduation Medium of Duration (Years) Month & Year of % of Marks
Degree Title Instructionn Passing

If Pursuing
Graduation Medium of Duration Expected Month & Year of % of Marks
Degree Title Instruction (Years) Completion
BOA Englich August 2022|78.1/%
 MARKS SECURED IN THE GRADUATION
Or igibily criterion, the aggregate percentage of marks secured in all the subjects of al the years shall be taken into

account.

Plo a r 7 e m e s t e r details as applicable, In case resiults are awalted indicate as A

Semester- Semester- Year-wise

Academic Year Marks Secured Total Marks Marks Secured
Marks Secured Total Marks
Total Marks
1st Yoar
500 342 500 312 lo00 654
2nd Year
S09 433 500 488 1000 920
3rd Year
500 S00
4th Year

The studerts pursuing graduation have to indicatle marks upto curentsemesterl yoar

(c)Have you taken coaching for any B-School Admission Tests7

Yes No. yes', please provide details:

Coaching Center Name:

wORK EXPERIENCE Please enclose the Experience Cerifcatesfrom your Employer

Years of Experience yrs
Company Name

4. How do you propose to

fund your education? Please tick ()
Educational Loan from Banks Loans from Relatives/Others
Parent's Support

5. HEALTH
Self
Did/Do you suffer from any major illness/disability
in the pastpresernt? Please lickK ()
N o , If yes",please give details ;
Yes
FAMILY BACKGROUND
Father Mother
Name
Sheadaba Mhaa Name SAlta Rar Ral
Qualification MA G.Ed,LLB, Qualificaion S A
Occupabion Business Kealid
ProfessionalCentral Gov Occupation Business ProfessionalCentral Govt
State Govt Pubilic SectorPrhate Sector StateGovtPublicSectorPrhvateSector
Oters (pease specty) Ohers (please speciy
Designation Achi Designalion A.T.R Artist
Salarylnco Eopoo-Pm Salarylncom
OrganizationAt-hunaaada, o OrpanizatonMada sAgltha ata,
&Address ltnanaaqa,ghauani pactna|&Address Ashausanlpahla, kalabandi
alaha
Cy GhauaaniPAtAA oY hauaanipatna
Mobile 4122351 Mobile 4EBG 2343
Personal E-mal shesaduhamishaa OH0 Personal Emai mina.tathl95 Cal
mail. tom Com
CAMPUS PREFERENCES (Please indicate preferences for al campuses 1 for frst preference, 2 tor
second preference and so on)
1BS Ahmedabad 8 1BS Gurgaon 1BS Kolkata
1 1BS Bengaluu
41BSHyderabad 6 1BS Mumbai

1BS Dehradun 3 1BS Jaipur 5 1BS Pune

Disclosure, Legal Aspects and Regulations

Al the applicants to the l1BS Programs are advised to read the Disciosure, Legal Aspects and Regulations given below caretuly and understand the
contents clearnly, If they need any dlarifcations, they shouid contact the Admissions Oce at ibsar@/bsindia.org.
Provisional Admiss ion: Al admissions are treated as provisional unti they are duy confmed. The admission of candidates who are
admited to l8S campuses and who are in the final year of graduation wil be treated as provisional only, subject to their completion of graduation
requirements by May 2022 with 50%% aggregate marks. The last date for submission of the proof of graduation is November 01, 2022 taling which
the provisional admission may be canceled
WithdrawalL and Refund of Fee:
Admission fee:
The students who withdraw from the program on or beore 5.00 pm on May 15, 2022 wil be reftunded the admission fee by June 30, 2022 ater

eoucting the administratve charges as per UGc guidelines

installment of Fee:
1
Fee Paid is not refundable
I n the case where a provisional admission of a student is cancelled due to not soconing S0% marks in graduation, 75% of the 1" installiment shal

berefunded after adusting dues if any

Details of the Programs may be modified from tme lo time tor academc, legal, regulatory and operational reasons, The students will be govemed
of to
by regulations applicable tb hem ounng
the latest
uhe
reevant acaden a r of n y the puty asumes any labily any kind
whener of not such perons fey on tand even they nlom l85 of their relance on it.
this intormabon,
any person for providing
but ,gener maket, macro-economc govemmental regulatory
and trends,
The documents may stalementse,
contain forward-iooking
technological developments,court decsions, eave p 0
0
o s,scope for urther studies, career opportunities
for students from the BS. Such forward-iooking stalermenits conaneneren are suect 1o cetain rsks and uncertaintes that could cause actual
 results to difer materially from those reflecled in the forward-looking statements. 1BS undertakes no duty to update any forward looking statements,
reflect future events or circumstances.
to

EnrollmentAgreement: The "Application Form" constitutes the Enrollment Agreement (hereinafter referred to as the Agreement) between the candidate
andthe IBS. Entire Agreement: This Agreement constitutes and expresses the entire agreement and understanding between 1BS and the students
or 5S in reference to all matters herein referred to, all previous discussions, promises, representations, and understandings relative thereto, if
any, had between the paties hereto, béing herein merged. No Third Party Beneficiaries: Enrollment of any candidate, shall not entitle any person
(Unciuding, without limitation, members) to any rights as third party beneficiary. No Obligation to Services, etc.: BS has no obligation to render any
Services to the students beyond two years (being the period of study) after the date of enrllment. To clarify further, no obligation Disclosure, Legal
ASpects and Regulations of IBS shall survive beyond two years after the date of enrollment. Limitation of Liability: The liability of 1BS towards the
Students is limited only to the extent of the fee paid by them to IBS. To clarify further, 1BS shall not be liable to the students for punitive, exemplary,
special, indirect, or consequential damages, including, without limitation, lost profits. 1BS shall also not be liable to fee paid to other organizations.
ASSIgnment: The students of 1BS cannot assign this Agreement or any part thereof. 1BS may, without necessity of the students' consent assign its
ngnisand obligations under this Agreement to a successor organization. Force Majeure: 1BS shall not be liable for delay or failure in performance
o any or its Obligations under the Agreement when such delay or failure arises from events or circumstances beyond the reasonable control of
l65 (uncluding, without limitation, acts of God, fire, flood, war, explosion, sabotage, terrorism, embargo, civil commotion, acts or omissions of any
govemment entity, supplier delays, communications or power failure, equipment or software malfunction, or labor disputes). Indemnity: Astudent
ot 155 agrees to indemnify, defend and hold IBS harmless from and against any and all loss, damage, liability and expense (including reasonable
attormeys fees and costs) arising out ofanythird party claim, action or proceeding based directly or indirectly on the acts of omission or commission
bythe member or his/her agents, the breach or alleged breach or failure to comply with any applicable laws or regulations, concerning the practice
ofprofession of management. Arbitration: All disputes relating to or arising out of this Agreement pertaining to 1BS campuses shall be settled by
relerence to arbitration only and not by recourse to the courts of law, as per the applicable Indian Law including the Arbitration and Conciliation Act
of 1996, Arbitration shall be conducted by an arbitration tribunal consisting of a single member only. The institute's nominee shall be the 'persona
designata as an arbitrator. The venue of arbitration shall be Hyderabad, India. The arbitration clause shal however not apply if 1BS and/or the
auithonzedagent decides to prosecute any student for any criminal offences, including but not limited to dishonor of postdated cheques. Applicable
Law With respect to 1BS campuses the Agreement shallbe deemed to have been made in Hyderabad in the State of Telangana and accordingly
the same shal be govemed by the laws of the State of Telangana, India. The courts of Hyderabad shall alone have the exclusive jurisdictionto
entertain any dispute/judicial proceeding arising out of or in relation to this agreement.

Legal Status
BS Hyderabad, BS Bangaloreare the constituents of the ICFAI Foundation for Higher Education (FHE), a Deemed-to-be-University under Section
3 of the UGC Act, 1956. The programs offered are: Two year full time MBA program and PhD program.

BSDehradunisaconsituentof theICFAIUniversity, Dehradun.The ICFAI University, Dehradunis established through an Act ofthe State Legislature
of Utarakhand and is recognized by UGC under Section 20 of the UGC Act. IBS Dehradun offers the MBA program.
BS Jaipuris aconstituentofthe ICFAI University, Jaipur The ICFAI University, Jaipur has been notfed by the Government of Rajasthan (Act No.
20 of 2011). 1BS Jaipur offers the MBA program.
1BS campuses at Ahmedabad, Gurgaon, Kolkata, Mumbai and Pune are the constituents of The ICFAI Society. These campuses offer two year ful
time Post Graduate Program in Management. The ICFAI Society do not award any
degrees/ diplomas within the purview of prevailing regulations
of AICTE/UGC.
BSAT 2021 bulletin is issued by 1BS Admissions Office on behalf of the ICFAI Foundation for Higher Education [IFHE (Deemed-to -be University)]
The ICFAI University, Dehradun; The ICFAI University, Jaipur and The ICFAI Society.

8. DECLARATION

I certify that the information presented in this Application Form is accurate, complete and honest to the best of my knowiedge. I certify that Iam aware
of the eligiblity criterion for the program is 50% in graduation and fee refund policy in the event of failure to fulfill the eligibility criteria. I understand
and agree that any inacurateinfomation,misleading information or omission willbe a cause for the withdrawal of any offer ofadmissionorfor
disciplinary action, dismissal or revocation of diploma, certificate, or degree if discovered at a later date
I certify that have never been expelled from any college, not convicted by any court and no proceedings are pending against me
lunderstand that all admissions are based strictly on merit and declare that I will not violate the rules against canvassing directly or indirectly to seek
admission and/or to seek any undue/special favors outside the framework of rules in force from time to time. I hereby understand and accept that
the decision of admission by the Admissions Committee is final and binding on me.

Place. 3hauani Pabma.

Date150.42022
Sarma Ranan Mishna
Applicant's Signature

1BS, January 2022.All nights reserved.