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Indian Institute of Management,Lucknow

Application for Executive Fellow Programme inManagement (2!"#

IMP$%&A'& I'&%)*&I$'

Before filling this application form read the instructions and programme details

provided Online at http://www.iiml.ac.in (Executive FPM Announcement

)Fill in the Application Form in CAPITAL letters only.

 A candidate is eligible to submit applications to a maximum of two areas. In suchcases candidates who choose to apply to two areas are re!uired to submitseparate application forms with all supporting documents to be sent together

"lease enclose copies of #$th #%th and graduation post&graduation mar' sheetsalong with each set of the form. Also enclose a copy of (corecard of )A* / +A*, /+-A* / +, F/0,* 12+)/)(I3 and II- 4uc'now 5-" 1Admission *est3. Ifshort listed all certificates 1originals3 should be produced at the time of interview.

The form should be complete in all respects. Incomplete forms will not beconsidered. Strike out whichever portion is not applicable.

"lease enclose a Demand Draft of Rs.!!!"#(Rs. 500/- for SC/ST

candidates)with the Application Form drawn in favor of I06IA0 I0(*I*2*, OF-A0A+,-,0* 42)70O5 payable at 6elhi .*his covers the application fee forapplying to two areas.

IMP$%&A'& ELI+IILI&- *A&E+$%- .E&AIL

*A& +A&E /MP Admission &est

Reg. No: Reg. No: Reg. No

Percentile Percentile Percentile

Score Score Score

Year Year Year  

)+* 0%F1'E& +MA&1+%EP+.M from IIM1AACS$"A%$A"&'(IS accreditedInstitutes

Reg. No Reg. No: CGPA

Year Qualified Percentile

/MP1IPM1P+PAM from IIMs1AACS$"A%$A"&'(IS accredited

Institutes

Score Course

Year CGPA

A%EA $F PE*IALIA&I$' (&ick t3e relevant ox#Agri-Business

ManageentBusiness !n"ironent Business Counication #ecision Sciences

$inance % Accounting&uan Resources

Manageent

'nforation ecnolog*

%S*stesMar+eting Manageent

,erations Manageent Strategic Manageent Sustainale Manageent //////////////////

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PE%$'AL .A&A

 Nae (in caital)

#ate of Birt

(dd==****)

Gender Male $eale

 Nationalit* Marital Status Married ;narried

Categor* SC S 3BC P& G!N Blood Grou

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Address4

Address 0

Cit* P'N

Pone=Moile !ail

Academic Performance

!ducation

Stage  Nae of teBoard=

;ni"ersit*='nstitute

Mont % Year of 

!/aination Su>ects=

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(if an*)Mont Year  

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&iger Secondar*

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Bacelors

#egree

Masters

#egree

Professional

#egree

(CA='C9A)etc.

 An* ,ter 

Please account for rea+ in *our acadeic career2 if an*

  

  

ADards=Medals=Pri?es=Scolarsis=Certificates=&onors2 etc. (Mention onl* tose related

toAcadeic=Professional Acti"ities)

 No. Nae of te ADard ADarding 'nstitution Year 

4.

0.

otal 9or+ !/erience as on  +0t  une 0&5   *ears onts and

 da*s.Eist all *our Dor+ e/eriences in descendin order (atest first) ;se ultile

lines as needed.

(o not incude trainin, *ro1ect $or#, $or# done as an intera *art of curricuar

re2uire!ent, and *art ti!e $or#)3

/ork Experience (Please mention full-time jobs only)

 No.  Nae of ,rgani?ation

#esignationReorting to(#esignation)

 Nature of #uties

Period otal

!/erience

in onts

Montl*Salar*$ro o

4.

0.

F.

8.

5.

.

H.

Ma4or Extra5*urricular Activities16o77ies

 No. Acti"it* Your Role

Year  ADards=Pri?es=

&onorsif an*

Rear+s$ro o otal

4.

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0.

Annexure9rite a 433 Dord Anne/ure for eac of te folloDing and attac as searate seets Dit tis alication

4. Stateent of Purose#escrie *our career goals and te reasons for *our interest in te $elloDsi

Prograe in aout 433 Dords.

0. Pre"ious Researc !/erience&a"e *ou done an* researc ro>ect=e/erient=field Dor+ as a art of *our Masters

degreeI Please Drite a rief suar* of one suc Dor+ in 433 Dords.

F. Proosed Researc Acti"it*is is not *our researc roosal. is is >ust *our initial idea aout te researc *ou

Dant to understand doing *our felloDsi rogra.

.eclaration

' certif* tat te articulars gi"en * e in tis for are true to te est of * +noDledge and

 elief. ' +noD tat at an* tie if te inforation furnised * e is found incorrect2 *candidature Dill e cancelled iediatel*.

Place

#ate Signature of te Alicant

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