INDIAN INSTITUTE OF MANAGEMENT INDORE

FIVE YEAR INTEGRATED PROGRAMME IN MANAGEMENT (IPM)

Commencing in August 2017

Last date for receipt of application at IIM Indore: May 15, 2017

INSTRUCTIONS
1. This application form is a key part of admission process and important for your selection. Complete and accurate information are
extremely important. Incomplete or false information will adversely affect your chances of selection. (All information should be
filled in block letters only by using a ball point pen)
2. Admission granted on the basis of false and / or misleading information will be ipso facto null and void.
3. In all matters relating to admission to the five integrated programme, the decision of the Institute's authorities will be final and
binding on the applicant.
4. No correspondence will be entertained from the applicant regarding his/ her non-selection.
5. Please submit your application so as to reach IIM Indore on or before May 15, 2017 along with self-attested copies of academic
marksheets/certificates along with Demand Draft.
6. IIM Indore will not be responsible for any postal delay.
7. The application fee of US $50 (US Dollar Fifty only) shall be paid (non-refundable) by Demand Draft (DD) drawn in favour of
Indian Institute of Management Indore, payable at Indore

Application Fee Details;

Drawee Bank Branch Location Amount :

DD/BC No DD/ BC Date

(I) PERSONAL DATA

Name of the Candidate

(As given in the Std.X Affix your recent
/SSC/Equivalent Marksheet)
passport size
colour photograph
Date of Birth Age as on July 31, 2017 here
D D M M Y Y Y Y Years Months

Gender (Tick appropriate one)

Male Female Transgender

Correspondence Address:

Address Line 1:

Address Line 2:

Address Line 3:

City:

State: . Pincode: ..

Email Id (Candidates):. Mobile No. (Candidates): .

Email Id (Guardians): .. Mobile No. (Guardians): .

Family Income (Total):

Five year Integrated Programme in Management at IIM Indore Application Form 1

 (II) ACADEMIC QUALIFICATIONS

A. Provide complete and accurate information on examination marks in all columns.

B. Wherever you have received letter grades or grade points instead of marks, provide equivalent marks and attach a certificate from competent
authority explaining the method of conversion. Where such conversions are not possible, please provide an explanatory note in the additional space
provided at the end of this page. The Admission Committee's decision in such cases would be final.

Standard Name of Board/ Year Total Max. Total % Marks / Class/ Division/
University Marks/ Marks/Grade Grade Rank*
Grade Obtained Obtained

Standard X /SSC
/equivalent
examination
Standard XII
/HSC/Diploma
/equivalent
examination
*Please produce certificates/ evidence if grade is mentioned.
* Students who are studying in XII Std. are required to produce certificate as per the format given in Page: 5.

Standard From To Core subjects Marks/ Other subjects Marks/ No of

(Yr) (Yr) Grade Grade attem
obtained obtained pts

Standard X
/SSC
/equivalent
examination

Standard XII
/HSC/Diploma
/equivalent
examination

Space for explanation of letter grades / grade points/ any other relevant information relating to academic qualification

(III) SAT Score details

SAT Score Card

(SAT scores obtained during January 1, 2016- March 31, 2017 are only valid)
Writing Section Critical Reading Section Mathematics Section Overall

(..out of 1600)

Five year Integrated Programme in Management at IIM Indore Application Form 2

 (IV) IPM Interview Centre

Choice of Center for Written Ability Test (WAT) & Personal Interview (PI), which will be held (tentatively) in June, 2017, if shortlisted:
1 2 3
PI Centre Preference
(Bangalore/Chennai/Delhi/Guwahati/Hydera
bad/Indore/Jaipur/Kolkata/Lucknow/Mumb
ai)

(V) SCHOLASTIC ACHIEVEMENTS

Scholastic Achievements: Please list scholastic awards or scholarships conferred on you during your School education at Secondary and Higher
Secondary or Equivalent level in curricular, co-curricular and extra curricular activities at district, state, and national level. You need to produce
certificates in support of your claim.

(VI) CAREER PLANS

Why do you wish to go in for a management education through five integrated programme? (Limit your response to 100 words)

(VII) MEDICAL HISTORY

Please state whether you have any existing physical disability or any chronic illness, including mental illness, which could affect your studies at the
Institute. If you have suffered from any chronic illness, including mental illness, in the past, please provide details below:

Nature of illness When suffered Date of completion of Remarks, if any

treatment
1.

2.

It is mandatory for all applicants to ensure that they are medically fit for joining the programme and they shall get the medical fitness certificate from
authorised doctor/ hospital preferably from Government Hospitals (at the time of registration to the programme).

Five year Integrated Programme in Management at IIM Indore Application Form 3

 (VIII) DECLARATION
I clearly understand that if I am selected, I will be allowed to join the programme only if I satisfy all requirements of the programme including the
submission of a certificate at the time of registration from Principal of my school that except for declaration of results, I have completed all requirements
for obtaining XII Std / Higher Secondary/Equivalent qualification and that I would have to produce evidence (mark sheet/ certificate) of having passed
the XII Std/Higher Secondary/Equivalent examination on or before the date of admission. Non-fulfilment of these requirements will automatically result
in the cancellation of the provisional admissions offer and no refund of fee will be made.

I certify that the particulars given by me in this application are true to the best of my knowledge and belief. I understand that admission granted on the
basis of false and/ or misleading information will be ipso facto null and void. I agree to abide by the decision of the institute authorities regarding my
selection/ non-selection for the programme.

I also understand that application fee which I may pay is non-refundable and no claim will be made by me or on my behalf for the same.

I hereby certify that I am fulfilling the eligibility conditions like Age, Percentage of marks and Reservation Category (If applicable) as per Govt. of India
norms.

I undertake to produce the following documents at the time of Written Ability Test (WAT) & personal interview (PI), if called for:
Original and self-attested copies of all academic certificates / marksheets / certificates from School authorities evidencing proof of
all claims made in this application.
A duly signed copy of this application

Place: ..__________________

Date: ______________________ _________________________

Signature of the applicant

PLEASE READ THIS FORM ONCE AGAIN AND MAKE SURE THAT YOU HAVE COMPLETED ALL THE DETAILS
RELEVANT FOR YOU AND HAVE COMPLIED WITH ALL REQUIREMENTS.
INCOMPLETE APPLICATION ARE LIABLE TO BE REJECTED

Send in your completed application form so as to reach this office latest by May 15, 2017 along with DD/BC and
photocopy of the following: Proof of Date of Birth, 10th Marksheet, 12th Marsheet (or provisional Certificate).

To,
The Admissions Office
Indian Institute of Management Indore,
Prabandh Shikhar, Rau-Pithampur Road,
Indore 453556

Note:- No other documents to be attached with the application form except the above mentioned certificates.

Five year Integrated Programme in Management at IIM Indore Application Form 4

The below certificate is applicable only for candidates appearing in Standard XII/ HSC/Diploma/
Equivalent Examination only (in session 2016-17)

This is to certify that Mr./Ms._________________________ is currently studying in the standard XII/

is awaiting the results, during the academic year 2016-2017 in this School/Institution.

This certificate has been issued to enable the candidate to apply for IPM 2017-22 Batch of IIM Indore.

Signature of the Authority:

Designation:Office

Seal:

Date:

Note: Ensure to obtain this certificate on School/Institutions letter head

Five year Integrated Programme in Management at IIM Indore Application Form 5