Indian Institute of Management Ahmedabad (IIMA)
APPLICATION FORM
ePGP 2017-19IIMA’s e-Mode PGP
Lead ID: ......................................... Prospect ID: ............................................
First Name: ................................................................................................................
Middle Name: ............................................................................................................
Last Name: ................................................................................................................
Enroll Center: ............................................................................................................
Batch Code: ..............................................................................................................
Study Center: ............................................................................................................
Email Id: ....................................................................................................................
Mobile No.: ................................................................................................................
Personal Details
Father’s/Mother’s/Husband’s Name: .........................................................................
Date of Birth:
Alternate Email: .........................................................................................................
Nationality: ................................................................................................................
Correspondence Address
House No.: ................................................................................................................
Street/Block: ..............................................................................................................
Locality: .....................................................................................................................
State: .........................................................................................................................
City: ...........................................................................................................................
Zip code: ...................................................................................................................
D D M M Y Y Y Y
Education History (Highest First)
Name of Exam
Degree Awarded
Year of Passing Division Marks (%) CGPA/CPIInstitute/University
Type of Admission Test: (Tick One)
If you are appearing for IAT, preference for test centers:
GMAT
Option(1)
Option(2)
Option(3)
CAT
IAT
Year
Year
Score
Score
Work History (Current Employment First)
Company Name
Designation Total Exp.Job
Description
Gross Monthly Emoluments in INR/US$
Exp. From Exp. To
Statement of purpose: (Why you want to enroll for ePGP and how it will benefit your career?)
Any additional information about yourself, you would like to share:
‘e’ stands for Electronic Mode (Interactive Onsite Learning)