MAULANA AZAD

NATIONAL INSTITUTE OF TECHNOLOGY BHOPAL– 462 003 DEPARTMENTOF MANAGEMENT STUDIES APPLICATION FOR ADMISSION IN MBA ACADEMIC SESSION 2015-2017 Affix here

1 Name (in Capitals):

Self Attested Latest 2. Father’s/Guardian name:

Passport Size

3 Occupation of Father/guardian

Photo

and address:

4 a) Address for communication (in Capitals)

b) Permanent address (in Capitals)

Email : Phone : Mobile : Pin

Pin (5) a) Date of Birth

:

b) Age ( In years) : (6) a) Nationality: b) Religion : c) Caste

:

e) Gender :

d) Caste category ( GEN/OBC/SC/ST/PWC) : Male/ Female

f) Martial status: Single/ Married

g) Identification No (Passport/Adhar /Voter ID):

1

(7) CAT/ GMAT Qualification:

Percentile/Score:

Year:

Reg.No. (8) Educational Qualification Examination/ Degree

Subject/ Discipline

Board/ University

% of marks/ Score

Grade/ Division

Year of passing

th

10 (Matric) 10+2/ equivalent

Under graduate

: (9) List of enclosures (attested Photocopies) a) b) c) d) e) f) g)

th

10 Mark sheet/ certificate Higher secondary /intermediate mark sheet/certificate Undergraduate mark sheet CAT/ GMAT score card Cast certificate (For Sc/ST/OBC/PH) Character certificate Transfer certificate

Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No

DECLARATION I hereby, declare that I have read carefully and understood the above information and that all the entries in this application form are true to the best of my knowledge and belief. Further, I assure that if admission is given to me, I shall abide by the rules and regulations, statutes, ordinance of the Institute and changes incorporated therein from time to time and shall maintain the discipline of the Institute.

Place Date

: : Signature of Candidate

2

Additional Information’s Advertisement No. Date Last date of submission Fee remittance Issuing bank & its branch SBI collect Amount Date Character & Antecedents report Subject Have you ever been subject to any disciplinary action, as a student, if so give full details Have you ever been dismissed/suspended from Institute /University Were you involved in any criminal, if yes, give full details If any case pending against you in the court, if yes, give full details Name and address of two referees Name & address

Comments

Name & address

E mail: E mail Mobile Mobile DECLARATION I hereby, declare that I have read carefully and understood the above information and that all the entries in this application form are true to the best of my knowledge and belief.

Place Date

: : Signature of Candidate

3

Verification sheet (For office use only)

1.

Name :

2. Category (GEN/OBC/SC/ST/PH

3. (1) UG

(ii) PG

4. Year of passing UG:

5. Year of passing PG

6. CAT/ GMAT: year of passing

7. Score:

Verified and admitted provisionally to the First semester Full Time course in: List of formalities to be completed:

By date:

(signature of the candidate at the time of admission) Date

(Signature) (member of admission committee) Date.

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