INDIAN INSTITUTE OF MANAGEMENT INDORE

Virtual Learning Programme for Executives (VLPE)

Post Graduate Certificate Programme in Investment Banking (PGCPIB)

Application Form
Last date for receipt of application at IIM Indore: 31st December 2018

INSTRUCTIONS
1. This application form is a key part of admission process and important for your selection. Complete and accurate information
are extremely important. Incomplete or false information will adversely affect your chances of selection.
2. Admission granted on the basis of false and / or misleading information will be ipso facto null and void.
3. In all matters relating to admission to the Virtual Learning Programme for Executives (VLPE), the decision of the Institute's
authorities will be final and binding on the applicant.
4. No correspondence will be entertained from the applicant regarding his/ her non-selection.
5. Please submit your application so as to reach IIM Indore on or before 31st December 2018 along with self-attested copies
of academic mark sheets and certificates
6. The application fee of Rs. 2950/- (Rupees Two Thousand Nine Hundred Fifty Only) inclusive of GST 18% shall be paid by
Demand Draft (DD)/Banker’s Cheque (BC) drawn in favour of “Indian Institute of Management Indore”, payable at Indore

Application Fee Details:

Name of the Candidate Drawee Bank Branch Location

DD/BC Date DD/BC No Amount (Rs.)

Mode of Learning (Any one of the following):

Classes live on your Laptop/Desktop at your place Or Classes at Study Centre

Choice of Centre for Exam and Personal Interview (PI):

Exam and Personal Interview (PI) Centre 1 2 3

Preference
(Please Refer List of PI and Exam Centre)

Choice of Study Centre for the Programme, if selected:

Study Centre Preference, if opted Classes at Study 1 2 3

Centre.
(Please Refer List of Study Centre)

(I) PERSONAL DATA

Name: _____________________________________________________________________________
(In CAPITAL letters) As recorded in your academic certificates

Father’s Name: ______________________________________________________________________ Affix your recent

(In CAPITAL letters) As recorded in your academic certificates passport size colour
photograph here
with signature
across.
Date of Birth

Day Month Year

Marital status: Single Married Gender: Male Female Transgender

1
Correspondence Address:

________________________________________________________________________________________________________

________________________________________________________________________________________________________

________________________________________________________________________________________________________

City: ___________________ Pin Code _______________ State _____________________

Phone: Mobile: Email:

Permanent Address:

________________________________________________________________________________________________________

________________________________________________________________________________________________________

________________________________________________________________________________________________________

City: ___________________ Pin Code _______________ State _____________________

Phone: Mobile:

(II) ACADEMIC QUALIFICATIONS

A. Provide complete information on examination marks in all columns. Marks stated in these columns MUST MATCH those in the
original mark sheets/transcripts.

B. Wherever you have received letter grades or grade points instead of marks, provide equivalent marks and attach a certificate
from competent authority explaining the method of conversion. Where such conversions are not possible, please provide an
explanatory note in the additional space provided.

Standard Name of Board/ University Year of Total Max. Total % of Marks

Passing Marks/GGPA Marks/CGPA (#)

10th//Secondary/equiv.

12th// Higher secondary

Graduation

Post-Graduation

Any other qualifications

2
 (III) EMPLOYMENT RECORD
➢ Mention ONLY full-time, paid work experience after Graduation in reverse chronological order (most recent experience first).
➢ Do not include training/ project work done as an integral part of any curricular requirement.

Experience
Organization & Location Designation From To
(In Months)

Total Work Experience

(IV) LIST OF DOCUMENTS

Please insure that the following self-attested copies of documents are enclosed while submitting application, if the
documents are not found, your application will liable to be rejected.

List of Documents Self-Attested

(Kindly write “Yes” or “No” in the box provide against the list of documents.) Photocopy
1. 10th Standard/ SSC or equivalent (Mark sheet)

2. 12th Standard/ HSC or equivalent (Mark sheet)

Bachelor’s Degree (Mark sheets)

• 1stYear Mark sheet (1st and 2nd semester)

3. • 2ndYear Mark sheet (3rd and 4th semester)

• 3rd Year Mark sheet (5th and 6th semester)

• 4th Year Mark sheet (7th and 8th Semester)

4. Bachelor’s Degree Certificate

5. Work experience certificate:

6. Identity Proof (Passport, Voter Id, Pan Card, UID, Driving License)

7. Others (if any, please specify)

(V) DECLARATION

I hereby declare that the information given by me in the application form is 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.

Place: ______________________

Date: ______________________ _________________________

Signature of Applicant

PLEASE READ THIS FORM ONCE AGAIN AND MAKE SURE THAT YOU HAVE COMPLETED ALL THE ITEMS RELEVANT
FOR YOU AND HAVE COMPLIED WITH ALL REQUIREMENTS. INCOMPLETE APPLICATION ARE LIABLE TO BE REJECTED

Send in your duly filled in Application Form (not later than 31st December 2018)
To
The Virtual Learning Programme for Executives (VLPE) Office
Indian Institute of Management Indore, Prabandh Shikhar, Rau-Pithampur Road, Indore – 453556, M.P. India