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Emba Adm Form 2014

This document appears to be an application form for the Post Graduate Diploma in Management - Part Time (PGDM-PT) program offered by the Goa Institute of Management for the 2014-2017 year. The form collects personal details of the applicant such as name, date of birth, address, educational qualifications, work experience, and a statement of purpose. It also includes a declaration by the applicant confirming the authenticity of the information provided and enclosed documents. The bottom section is for office use such as application receipt details and remarks from the admission committee.

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KaranGarg
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108 views5 pages

Emba Adm Form 2014

This document appears to be an application form for the Post Graduate Diploma in Management - Part Time (PGDM-PT) program offered by the Goa Institute of Management for the 2014-2017 year. The form collects personal details of the applicant such as name, date of birth, address, educational qualifications, work experience, and a statement of purpose. It also includes a declaration by the applicant confirming the authenticity of the information provided and enclosed documents. The bottom section is for office use such as application receipt details and remarks from the admission committee.

Uploaded by

KaranGarg
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 5

PGDM-PT

Number:

To be filled by office
APPLICATION FORM

GOA INSTITUTE OF MANAGEMENT, RIBANDAR, GOA


Post Graduate Diploma in Management Part time 2014-17

Name: ____________________ _________________


1.

2.

Surname

First Name

_________
Middle Name

Date of Birth: ____ - _____ - _______


DD

MM

YYYY

Photo

Age: _____ years _____ months

3. Address For Correspondence :


_____________________________________________________
_______________________________________________________

Ph.: _________ Mobile No. : _____________Fax: _________


Email id: ___________________________.
4. Permanent Address: __________________________________________
______________________________________________________________
Ph.: _____________________Mobile_______________________

5. Work Place Address : __________________________________


_______________________________________________________

Ph.: _________ Mobile No. : _____________Fax: _________


Email id: ___________________________

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1.
6. Educational data (Please give the aggregate percentage obtained )

Year of
Passing
10th

Main
Subjects

Name of School/
College/ University

Place /
City

Percentage

NA

12th
College (Degree)
Others*

* Other academic Degrees/ Master degree/Diplomas (Please specify).

7. Work Experience: (Dont include work experience which is part of your degree requirement)
Begin with the current job/ assignment / enterprise

Organization

Place

Nature of Work

From:

To:

Month Year

Month Year

Total Experience in Years and Months:


Submit attested copies of the academic and experience certificates along with the form.

8. How did you come to know of Goa Institute of Management & the Program?
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________

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9. STATEMENT OF PURPOSE -Why do you want to join this program? How will you
and your organization benefit from it? How do you want to develop yourself through
this program?
___________________________________________________________________________________________
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Declaration
(Submitted to Goa Institute of Management Ribandar, as required for the admission to PGDM-PT)

I, the undersigned, ____________________________________________________


solemnly affirm that:
1. I have a degree recognized by UGC/ AIU/ AICTE.
2. I have at least 50% aggregate marks at graduation.
3. I have enclosed the attested copies of following certificates with my
application. (Tick mark)
a. 10th
b. 12th / Diploma
c. Graduation
d. Post-Graduation
e. Professional Degree/ Diploma
i.
ii.
iii.

4. I have enclosed my work experience certificates (Self declaration in


case of entrepreneurs, family managed business) starting from latest.
a.
b.
c.
5. Any other relevant information :

I certify that the information given on the Application Form is true to the best
of my knowledge and belief.

Date:___________________________Signature:_________________________________

4/5

============================================================================= =

For Office use only :


Application form received On :_____ / ______/ 201
person.
Payments received in DD/ Cash

By : Mail / Courier / submitted in

Amount : Rs. _____________ Dated ___/ _____/____.

Drawn on _______________________ bank


Received by: ____________________________ Signature with date : __________________
Receipt number: __________________________ ( Receipt Book number _____________ )
DD / cash deposited on : _______/ ______ / 201 .
Received by account section on: ___ / ______/ 201 by Mr./ Ms._______________________
-----------------------------------------------------------------------------------------------------------Remark of the Admission Committee
The application of this candidate is accepted / rejected for
1.
2.
3.
4.
5.

5/5

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