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Annexure 1 Student Information Form

The document is a Student Information Form for the Master of Business Administration program at the Indian Institute of Management Sambalpur for the batch 2022-2024. It collects personal details such as name, gender, date of birth, parental income, contact information, educational background, and work experience. The form also includes a declaration section where students confirm the accuracy of their information and agree to abide by the institution's rules and regulations.

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chauhan199922
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28 views1 page

Annexure 1 Student Information Form

The document is a Student Information Form for the Master of Business Administration program at the Indian Institute of Management Sambalpur for the batch 2022-2024. It collects personal details such as name, gender, date of birth, parental income, contact information, educational background, and work experience. The form also includes a declaration section where students confirm the accuracy of their information and agree to abide by the institution's rules and regulations.

Uploaded by

chauhan199922
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Annexure - I

Indian Institute of Management Sambalpur


Master of Business Administration
BATCH 2022-2024
Affix
STUDENT INFORMATION FORM
photograph
CAT Id.

1. NAME IN FULL In English


[in block letters (As per High School Certificate)]
(As per High School Certificate) In Hindi

NAME IN SHORT (for Name Tag) 2. GENDER Transgender Female Male

3. DATE OF BIRTH 4. CATEGORY


GEN DAP
SC(GEN/ SCST
/ ST / NC-OBC)
NC-OBC EWS

Day Month Year


In case of EWS candidate please specify the name of certificate issuing authority
5. FATHER’S NAME MOTHER’S NAME

6. ANNUAL PARENTAL INCOME (Father, Mother, Self & Spouse) _


7. PHYSICAL ATTRIBUTE (In case of DAP)
Normal
Low Hearing Impairment Locomotors Disability/Cerebral Palsy
Vision/Blindness
8. ADDRESS FOR CORRESPONDENCE (with Pin Code)

_ E-mail
CONTACT No. Alternate Contact No.

9. CONTACT PERSON IN EMERGENCY


NAME
ADDRESS

CONTACT No. Alternate Contact No.


10. CITIZENSHIP 11. MARITAL STATUS

12. EDUCATIONAL BACKGROUND


(Qualified / Appeared in Final Exam) Science Arts Commerce Engg. Others
13. WORK EXPERIENCE
Organization Designation From To Total Months

Total Months of Experience


DECLARATION

1. The above information furnished by me is correct to the best of my knowledge and belief. I understand that in case any of the information
given by me is found incorrect, my registration is liable to be cancelled.
2. I hereby agree to abide by the rules and regulations pertaining to academic evaluation, general code of conduct, and all other rules and
regulations as stated in the MBA Manual.
3. I further agree to abide by any other rules and regulations that may come in force during the period of my study at the Indian Institute of
Management Sambalpur.
Date:
Signature of Student

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