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MANAGEMENT DEVELOPMENT INSTITUTE, GURGAON

PERSONAL DETAILS FORM FOR PGPM/PGP-HRM/PGP-IM 2014-16
Please fill in Block Letters

CAT REG NO:.. ......................................................................................................
Name(as per Xclass certificate): ................................ ................................ ................
Fathers Name:.
Mothers Name:....
INTERVIEW: DATE ................................ ............ TIME: .............................................
VENUE CITY: ................................ ............................... PANEL.
Passport - Yes No, if Yes, Passport No:- ..
Date of Birth

D D M M Y Y Y Y
Please tick () wherever applicable
Female Male Married Single
Indian NRI Foreign National PI PIO

Mailing Address








City


State




Academic Qualification
Qualification Name of the
Institution/Professio
nal Body State / UT
Name of the Board /
University
Year of
Completion
Marks (%)
or CGPA
Degree with
Discipline
Secondary
School (X)

Sr. Secondary
School (XII)

Graduate
Degree

Post-Graduate
Degree

Professional
Degrees








Paste a passport
size photograph in
the space provided
2


Work Experience
(Furnish detail s of full-time jobs starting first with the present job (excluding training periods) engaged in, after
completion of Bachelors Degree) (use a separate sheet if required)
Name of
organization
Designation

Nature of Duties

Designation of
the Person
Reporting to
Period
from To
dd/mm/yy
Emoluments
per annum
(in Rs.
Lacs)
Turnover of
Organization
(in Rs. Lacs)




Total Experience - as on 31
st
December 2013

YEARS - MONTHS
Academic/Professional Awards/Medals/Prizes/Scholarships/Certificate/Honours, etc.
(Excluding those for extra -curricular activities)
Name of the Award Awarding Institution
Level
(State/National)
Basis of Award Year





Major Extra-Curricular Activit ies/Hobbies
Activity Role
Level
(State/National)
Year
From To
Honours (if any) Remarks





Declaration
All entries made in this application from are true to the best of my knowledge and belief. I am willing to produce
original certificates in support thereof if asked to do so at any stage. I agree to abide by decisions of
Management Development Institute, Gurgaon on all matters regarding this application.


PLACE



DATE

D D M M Y Y Y Y

(Signature)