A P P L I C A T I O N

Application Form

PAKISTAN INSTITUTE OF MANAGEMENT

DIPLOMAS FOR PROFESSIONAL DEVELOPMENT Applied for Diploma in:

Health, Safety & EnvironmentName (block letters)

Father's Name

National Identity Card No.

Gender:

Male

Female Date of Birth:

Home address

Telephone No.

Cell No. E-mail:

Business address:

Telephone No.

Fax No.

Which address should be used in any future correspondence with you? (Please tick box)

Home

Business

Other (please specify)______________________

____________________________________________________________________________

Telephone No. Fax No.

Employment Record:

(Last five years starting from current employer) Business ActivityYour title & departmentPeriod of employment

Please give a brief description of your present position and responsibilities

FINANCIAL SUPPORTWho will provide financial support for your place on the Diploma for Professional Development?

(Please tick box)

Employer *

Self

Other (Please specify)________________________

* Nominating Authoritys letter must accompany with Application Form.

EDUCATIONThis section refers to the schools, colleges and universities attended. In each case please state the name and

location of the institution, the periods of attendance, the subjects studied and the qualifications and grades obtained.

Name and Place of InstitutionYearSubjectQualificationsGrade/CGPA

Professional or other post-graduate certificationYear

NOTE: Please enclose all required documents. Incomplete forms will not be entertained

PIM reserves the right to reject any candidate without assigning any reason.DECLARATION

For Office Use Only

Candidate No._______________

Registration No.______________

I hereby stand committed to the above information provided by me as true and accurate and agree to accept the terms and conditions of this Diploma.

Signature of applicantDate _____________________

One Recent Photographs

4PD-001 Pakistan Institute of Management