Indian Institute of Management Rohtak

Application Form For Doctoral Programme

(Fellow Programme in Management)
Application Form No. ____________________ FPM Bulletin No. ______________________
Instructions for filling the Application Form
1.
2.
3.
4.
5.

Fill in the Application Form in capital letters.

Please enclose copies of all certificates and testimonials.
Please enclose two copies of passport size photograph.
All certificates (originals) should be produced at the time of interview.
The form should be complete in all respects. Incomplete forms will not be considered.
6. Strike out whichever is not applicable.

Affix your recent

photograph
(5cmx4cm)

1. Personal Data
1.1 Name:

1.2 Date of
Birth
D D M M Y Y

1.3 Sex

1.4 Marital Status

M

2. Qualifying Examination: C A T / G A T E / G M A T / G R E / J R F / P G D M / O t h e r
(Please tick the right one and enclose the copy of mark sheet / scorecard or Grade sheet)

2.1 Have you appeared for CAT-2013? If yes,

give your CAT Reg. No.
2.2 If not, give details of
others: (Reg.No./Date

Year

CAT

of Appearance)

2.3 Test Score*

Overall

Section 1

GMAT

GRE (Gen/
Advanced)

Section 2

JRF of UGC/
CSIR

Section 3

GATE

Section 4

(if available)

Score
Percentile
*Attach score card/certificates

2.4 Nationality (If not Indian Resident or NRI, mention country name)
Indian
NRI
PIO

Other Foreign

2.5 Addresses:
(a) Mailing:

Pin

0 0 0 0 0 0

Pin

0 0 0 0 0 0

(b) Permanent:

(c) Landline No. with code: _________________________ Mobile No. __________________________

(d) E-mail ID _________________________________________________________________________

3. Family Details
Fathers Name/ Spouses Name (if married):________________________________________________
Occupation: __________________________________________________________________________
Phone No. : ____________________________________ Mobile No: ___________________________
4. Academic Performance
4.1 Education
Stage

Title of
Qualificati
-on

Name of the Board/

Univ. /Institute

Month & Year

of Exam
Month
Year
M

Subjects/
Specialization

Max.
Marks/
CGPA
for the
Exam.

% of
Marks/
CGPA
Obtained

Class/Div.
Obtained
(if any)

th

SSE (10 )

HSSE
(10+2)
Bachelors
Degree

Masters
Degree
Professinal
Degree
(MBA/LLB/
CA/ICWA

etc.)

Any other

4.2 Please account for break in your academic career, if any: ________________________________

______________________________________________________________________
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________________________________________
4.3. Awards/Medals/Prizes/Scholarships/Certificates/Honors, etc.
(Mention only top three and those related to Academic/ Professional Activities)

No.

Name of the Award

Awarding Institution

1
2
3
5. Total work experience in full-time jobs:__________ Years _______________ Months.

Year

5.1 Work Experience: From most recent to backward (Please mention full-time jobs only)*
Designation Reporting to
No.
Name of
Nature
Period
organization
(Designation)
of
From To
Duties

Total
Exp. in
months

Monthly
Salary
in Rs.

3
*(Add sheets if required)
6. Extra-Curricular Activities/Hobbies* (Please mention only top three)
Activity
No.

Your Role

Year
From

To

Total

Awards/Prizes/Honors, Remarks
if any

3
*(Add sheets if required)
7.

Why are you interested in the Fellow Programme in Management?

(Please write in 150 words only)

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8. Previous Research Experience: (Explain any research project/experiment/field work completed

as part of your Masters degree or afterwards. If not applicable, present your views on an
important issue in your area of interest. Please write in 150 words only).
Note: If you have any published research work, a copy or, if its size is large, its abstract may be enclosed.

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9.

Proposed research work: (Please write about your possible idea that could be taken up for the
doctoral research by you. Please write in 150 words only).

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10. Area of Specialization (Select only two and give your order of preference (I or II))
S. No.

Area

1
2
3
4
5
6
7
8

Business Environment
Financial Management
General Management
Human Resources Management
Information Technology Systems
Marketing
Operations
Strategic Management

Preference

11. Referees: (Two are compulsory)

1.Name:__________________________________
Address:__________________________________
_________________________________________
_________________________________________
_________________________________________
____________________________Pin:__________
Email: ______________ Phone:_______________

2. Name:__________________________________
Address:__________________________________
_________________________________________
_________________________________________
_________________________________________
____________________________Pin:__________
Email: ______________ Phone:_______________

Note: Confidential referee recommendations need to be enclosed with the application in the given format.
12. Details of Demand Draft:
Name of issuing bank ___________________________________________ Place _______________________
DD No. ______________________ Amount _____________________ Date of issue _____________________

13. Details of enclosures sent with the application:

1.

________________________________________ 3. ________________________________________

2.

________________________________________ 4. ________________________________________

14. Declaration
All the details provided by me in this application form are true to the best of my knowledge and belief. I
will produce the original certificates on demand at any stage of the programme.
Place:_________________
Date:__________________

Signature of the applicant

Last date for receiving the completed application forms at IIM Rohtak is January 25, 2013
Please mail the filled in application form to
Officer-in-charge, FPM
Indian Institute of Management Rohtak
MDU Campus, Rohtak, Haryana 124 001
FOR OFFICE USE ONLY
Areas Applied

Qualifying Test
E-mail

Area Code

:
:

INSTRUCTIONS AND INFORMATION TO

APPLICANTS ON THE APPLICATION PROCEDURE
1. Applications for the Fellow Programme should be sent only in the prescribed Application
form, which can be obtained from the FPM Office of the Institute by sending a request by email/post/fax along with a DD of Rs. 500/- as non-refundable application fee. The DD
should be drawn in favour of Indian Institute of Management Rohtak payable at Rohtak.
Alternatively, you can download the form from the IIM Rohtak Website and send the
application fee of Rs.500 as DD along with the Application. Applications without the
application fee will not be accepted.
2. You may choose to apply to a maximum of two areas from the eight choices. For each area
selected, you must submit a separate copy of application form (complete in all respects).
However, there is no need to pay a second fee.
3. For each area applied for, two letters of recommendation in prescribed format are required.
Blank format for recommendation letters and the instructions to send these are enclosed. So,
a candidate applying in one area should send two and one applying in two areas should send
four letters of recommendations.
4. Ensure that you respond to all items in the application form (Use N/A for items which do
not apply to you).
5. Please submit the documents in support of the application according to the instructions given
below under Supporting Document.
6. The completed application form with enclosures must reach the following address latest by
January 25, 2013.
The Officer-in-Charge
Fellow Programme in Management
Indian Institute of Management Rohtak
MDU Campus, Rohtak 124 001
E-mail: fpmoffice@iimrohtak.ac.in Phone: 01262-228511 Fax: 01262-274051
7. While contacting Fellow Programme Office, please quote your application Number and/or
FPM Bulletin number and the area of specialization as opted for in this application.

SUPPORTING DOCUMENT
A. Official Transcript:
Please provide official transcripts of records and/or mark sheets (or attested copies of the
same) in support of your academic qualifications. Attestation may be done by a College or
University authorities, regular faculty of any IIM, or any Gazetted Officer whose
designation should be given. The key to the letter grade system should be included
wherever necessary.
B. Copy of the Score Card/Certificate of CAT, GMAT, GRE (General/Advanced), UGC/CSIR
JRF or GATE.
C. Writing & Research:
Please enclose with this application any published or unpublished research work which you
might have completed. You may give abstracts or summaries if the entire document cannot
be sent.
6

Indian Institute of Management Rohtak

Doctoral Programme
(Fellow Programme in Management)
Letter of Recommendation
For an applicant to the Doctoral Programme at IIM Rohtak
(The candidate has applied for the Fellowship Programme (equivalent to a PhD Programme) at IIM Rohtak. You are requested to seal the
envelope containing this letter and sign across the seal. You may either hand over the sealed envelope to the applicant or mail it directly to
Officer-in-charge, Fellow Programme in Management, Indian Institute of Management Rohtak, MDU Campus, Rohtak 124001, India so as to
reach the office by January 25, 2013.)

Name of the applicant:

(Use upper case)
Area Applied for:

FIRST

MIDDLE

LAST

_______________________________________________

1. I have known the applicant for __________ years and ____________ months.
2. He/she has been (please check most appropriate answer):
A student in my course(s) ________
A personal friend or acquaintance ________

My advisee ________
Other (please specify) _____________

3. Compared with a typical group of students/persons I have encountered at my institution/in my contact, I would
rank him/her as indicated below (please tick as appropriate):
CATEGORY

EXCELLENT
Top 5%

VERY GOOD
Next 10%

GOOD
Next 20%

FAIR
Next 25%

POOR
Bottom 40%

NO BASIS FOR
JUDGEMENT

Academic Strength
Motivation
Teaching Potential
Research Potential
Communication
Ability
Writing Ability
Overall Rating
4. Please write briefly about the strengths of the candidate:

_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
5. Please write briefly about the weaknesses of the candidate:

_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
6. Comments on the suitability of the candidate to a doctoral Programme (please use separate sheet, if desired):

_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Your name: ____________________________

Signature:_________________________________________

Designation: ___________________________

Institute affiliation:__________________________________

Address:

__________________________________________________________________________________

_____________________________________________________________________Pin_____________________
Email:_________________________________

Phone:____________________________

Indian Institute of Management Rohtak

Doctoral Programme
(Fellow Programme in Management)
Letter of Recommendation
For an applicant to the Doctoral Programme at IIM Rohtak
(The candidate has applied for the Fellowship Programme (equivalent to a PhD Programme) at IIM Rohtak. You are requested to seal the
envelope containing this letter and sign across the seal. You may either hand over the sealed envelope to the applicant or mail it directly to
Officer-in-charge, Fellow Programme in Management, Indian Institute of Management Rohtak, MDU Campus, Rohtak 124001, India so as to
reach the office by January 25, 2013.)

Name of the applicant:

(Use upper case)
Area Applied for:

FIRST

MIDDLE

LAST

_______________________________________________

1. I have known the applicant for __________ years and ____________ months.
2. He/she has been (please check most appropriate answer):
A student in my course(s) ________
A personal friend or acquaintance ________

My advisee ________
Other (please specify) _____________

3. Compared with a typical group of students/persons I have encountered at my institution/in my contact, I would
rank him/her as indicated below (please tick as appropriate):
CATEGORY

EXCELLENT
Top 5%

VERY GOOD
Next 10%

GOOD
Next 20%

FAIR
Next 25%

POOR
Bottom 40%

NO BASIS FOR
JUDGEMENT

Academic Strength
Motivation
Teaching Potential
Research Potential
Communication
Ability
Writing Ability
Overall Rating
4. Please write briefly about the strengths of the candidate:

_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
5. Please write briefly about the weaknesses of the candidate:

_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
6. Comments on the suitability of the candidate to a doctoral Programme (please use separate sheet, if desired):

_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Your name: ____________________________

Signature:_________________________________________

Designation: ___________________________

Institute affiliation:__________________________________

Address:

___________________________________________________________________________________

_____________________________________________________________________Pin_____________________
Email:_________________________________

Phone:____________________________________________

10