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Subsequently, ten times the number of candidates required to be admitted will be called for Stage II from the top of this list. The number of seats in each category is given in Table 2. Table 2: Number of Seats at IIM Kashipur for the Academic Year 2011-12 Category Number of Seats SC 9 ST 4 PWD 1 NC-OBC 16 General 30 Total 60
Stage II Stage II of the admission process involves the assessment of the candidate by an interview panel, which will conduct the Personal Interview The weights for these components as well as that of CAT-2010 examination are as shown in Table 3: Table 3: Various Components & Weights Component Personal Interview CAT - 2010 Total
Admission Office Indian Institute of Management Lucknow Prabandh Nagar, Off Sitapur Road, Lucknow - 226013
SR
A. PERSONAL DATA
1. 2. Name_________________________________________________________________ Date of Birth d 3. Address for correspondence d m m y y y y Affix your RECENT Passport size Photograph
_____________________________________________________ _____________________________________________________
PIN_______________________________E-mail id:____________________________________________________ 4. Contact Telephone No. with STD Code___________________________ Mobile No.___________________________ 5. 7. Annual Parental Income Rs. Category (Pl. tick) SC ST NC-OBC GEN 8. 6. Nationality 9. Sex (pl. tick) M F
Phy. Handicapped (pl. tick) 1 Low Vision/Blindness 2 Hearing Impairment 3 Locomoter Disability/Cerebral Palsy
B. ACADEMIC QUALIFICATIONS
B1. Pre-Bachelors Degree Examination(s) A. Fill only if a Board or a University Examination. B. Take into account only the marks in the subjects/papers which are counted for awarding class/division. Standard 10th 12th EDUCATIONAL BACKGROUND : (Pl. Tick ) AGRI ARTS COMM ENGG SCI OTHERS Board/University Year Max Marks Marks Obtained Class/ Division % of Marks Obtained
B2. Bachelors Degree Examination(s) Degree Obtained ________________________________Subject/Specialization____________________________________ College/Institute______________________________ University _______________________________________________ Year From 1st Year 2nd Year 3rd Year 4th Year 5th Year Total / CGPA Class / Division Obtained If you are appearing for the final year Bachelors Degree examination, indicate the time of examination If you have already completed the Bachelors Degree Examination, indicate month/year of completion B3 Month Year Date To Marks considered for award of Class/Division in Bachelors degree Max.Marks/GPA Marks/GPA Obtained % of Marks Obtained
Month
Year
Masters Degree / Post-Graduation / Professional Qualification (College/University/Institute attended)________________________________________________________________ Year From To Subject Max. Marks Marks Obtained % of Marks Obtained
1st Year 2nd Year 3rd Year Overall percentage of marks obtained
C.WORK EXPERIENCE * (Indicate only paid and full-time work experience, acquired after completing the Bachelors Degree. Apprenticeship, Articleship, Internship etc., which form an integral part of a course of study, should not be treated as work experience.)
Organization Designation From To Monthly Remuneration (Rs.) YY Reasons for leaving
DD
MM
YY
DD
MM
Nature of Responsibilities_________________________________________________________
________________________________________________________________________ ________________________________________________________________________
Total work experience (in months) as on 31.03.2011 * Please bring the total experience certificates and the copies of the first and last salary slips at the time of interview. D. EXTRA-CURRICULAR ACTIVITIES Please mention inter-collegiate, Institute and higher level activities only. These may include games and sports, cultural, literary and similar other activities. ____________________________________________________________________________________________________ ____________________________________________________________________________________________________
E. DECLARATION
I have carefully read the instructions and agree to abide by the decision of the institutes authorities regarding my selection for the programme. I certify that the particulars given by me in this form are true to the best of my knowledge and belief. I am aware, that, in case, I have given wrong / fractural information, then my admission will be withdrawn.
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PLEASE EXAMINE THIS FORM ONCE AGAIN AND MAKE SURE THAT YOU HAVE COMPLETED ALL THE ITEMS