INDIAN INSTITUTE OF MANAGEMENT CALCUTTA Application for Post Graduate Diploma in Management for Executives 2012-13

1. Personal Information Name Gender Marital status

First name

Middle name
Date of birth

Last name
/ / Affix self -attested recent colour photograph

Male

Female

dd/mm/yyyy

Married Low vision/ blindness

Single
Number children of

Disability

(if any)
Nationality

Hearing impairment

Locomotor disability
Place of birth

Cerebral palsy

City
Date of expiry

Passport number Place of issue Other citizenship Country of permanent residence Mother tongue Other languages known 2. Contact Information Company Present business address No. and Street City State Phone No. and Street Permanent address City State Phone Preferred communication address

Country / / dd/mm/yyyy

Country of current residence

Postal code Country Fax

Postal code Country Fax

Present business address

No. and Street City State Phone

Permanent address

Address given below

Postal code Country Fax Alternate email address 1

Email address

Preferred phone number 3. Preferences Interview location

Alternate phone number

Bangalore

Mumbai

Kolkata

New Delhi

Telephonic*

Accommodation

(During the course)

4. Application-fees

*Preference for telephonic interviews will be entertained only in exceptional cases There is a limited number of family accommodation available on campus. Students provided with family accommodation will be required to pay an additional Rs. Single Family 48,000/- per annum

INR 2000/- ( Non refundable) for Indian nationals and USD 100 for NRI / Foreign Nationals/ Applications sent from outside India. Bankers Cheque/Demand Draft should be drawn in favour of Indian Institute of Management Calcutta, payable at Kolkata, India / / Bankers Cheque/D.D Date No. dd/mm/yyyy
Bank details 5. Miscellaneous Information

The course fee ( Non Refundable ) for the PGPEX Programme is Rs. 14,00,000/- (Rupees Fourteen lakhs only) payable in four installments. Furthermore Rs. 20000/- (Rupees Twenty thousand) has to be paid as refundable caution deposit at the time of registration. *Education loans are available at competitive rates from leading banks subject to certain pre-conditions
How you propose to pay for this course? How did you come to know about PGPEX Are you a re-applicant?

Bank

Own fund

Other sources( Please specify)

Year of previous application Registration number

Website/Newspaper/other sources

No
6. Test scores

Yes

*GMAT - Graduate Management Admissions Test ( taken within last 36 months) The GMAT programme code for PGPEX is 9CP-HT-99. This score must be sent to IIM Calcutta through Pearson VUE within the application deadline Registration number
GMAT Test date Verbal score Quantitative score Overall score AWA score / / Percentile Percentile Percentile
dd/mm/yyyy

TOEFL

Percentile *TOEFL - Test of English as a Foreign Language TOEFL score should be provided as a proof of proficiency in English only if medium of instruction during study was not English Registration number Test date Overall score 2 / /

dd/mm/yyyy

TWE

*TWE - Test of Written English TWE score should be provided as a proof of proficiency in English only if medium of instruction during study was not English Registration number
Test date Overall score / /

dd/mm/yyyy

*IELTS - International English Language Testing System IELTS score should be provided as a proof of proficiency in English only if medium of instruction during study was not English
IELTS Registration number Test date Overall score 7. Academic qualifications / /

dd/mm/yyyy

Please attach attested/notarised copies of transcripts of all examinations passed. Use extra sheets if necessary
Institution name with full address
Exam/ Degree (Major)

Dates attended From To Year of passing

CGPA/ Percentage

Rank/Division

8. Work experience Aggregate full time work-experience

(In completed years and months as on st 31 March 2012 ) Managerial work-experience (In completed years and months out of aggregate work-experience given above)

Years

Months

Years
Name Industry Website Total employees Annual sales (USD)

Months

Your current employer

May we contact your current employer?

Yes

No

If yes, please give name, designation, postaladdress, e-mail and phone details (including country and area code)

Job title Your current job Area of expertise No. of reportees Your direct supervisor Title To whom does he/she report

Your job description

Please give a description of your exact job, including nature of work, major responsibilities etc. (If possible, draw an organization chart and give your job description. Use extra sheets if necessary)

9. Career summary

Please provide chronological details of your work experience below. List your present position first. Kindly note that you will be required to submit a certificate of employment from your last employer in case you are granted admission. Use extra sheets if necessary Name of organization
Industry Complete address including contact numbers Website address 1 Starting date Ending date Last designation Functional area of work Last drawn salary International exposure (if any) Reason for leaving Name of organization Industry Complete address including contact numbers Website address 2 Starting date Ending date Last designation Functional area of work Last drawn salary International exposure (if any) Reason for leaving Name of organization Industry Complete address including contact numbers 3 Website address Starting date Ending date Last designation 6 / / / / / / / / / / / /

Functional area of work Last drawn salary International exposure (if any) Reason for leaving Name of organization Industry Complete address including contact numbers Website address 4 Starting date Ending date Last designation Functional area of work Last drawn salary International exposure (if any) Reason for leaving Name of organization Industry Complete address including contact numbers Website address 5 Starting date Ending date Last designation Functional area of work Last drawn salary International exposure (if any) Reason for leaving / / / / / / / /

10. Activities and interests

Please list, in order of importance to you, any extra-curricular activities in which you are/have been involved (i.e., sports, politics, community activities, hobbies etc.) Use extra sheets if necessary
Activity/Interest Duration From To Level of involvement/ achievements etc.

11. Statement of Purpose

12a. Essay 1
Give detailed descriptions of three activities you performed in your workplace in the last five years which will help us assess your abilities and strengths. Use extra sheets if necessary

10

12b. Essay 2
Narrate an important/unusual incident of your life when you had to face a very demanding/challenging situation. How did you overcome the situation? What lessons did you learn from this incident? Use extra sheets if necessary

11

12c. Essay 3 (Only for re-applicants)

What are the changes in your profile vis--vis previous years?

12

12d. Essay 4 (Optional)

Anything else you would like to highlight in support of your application

13

13. References
Two letters of recommendation in the format given must be sent to the Institute within the application deadline date. The recommenders should separately seal the envelopes and sign on the flap. Please l ist below the name and complete ad dress o f each person to w hom you have given a recommendation form. Each should be well acquainted with your intellectual abilities, academic performance, and personal character. At least one of these two letters should be by someone from industry who is familiar with your professional achievements Recommender 1 Name Complete address Organization Relationship with applicant Email Mobile Phone Fax Recommender 2 Name Complete address Organization Relationship with applicant Email Mobile Phone Fax Letter of recommendation by the recommender in the prescribed format may be sent in any of the following manner. a ) Duly filled in and signed Recommendation letter ( in a sealed envelope) and also signed by the Recommender on the envelope flap may be sent by the candidate along with other documents. b ) Recommender may also send the hard copy of the Recommendation Letter in the prescribed format duly signed ( both in the recommendation form and also on the envelope flap) directly to PGPEX Office Indian Institute of Management Calcutta Diamond Harbour Road, Joka Kolkata 700 104, India c ) Recommender may also send the scanned copy of the Recommendation Letter duly signed by him/her via e- mail directly to pgpex@iimcal.ac.in Please note that the institute will not be responsible if the recommendation letter is not received by us within the due date ( either hard copy or e-mail ) . In the absence of the recommendation letter within due date , the application is liable to be rejected . 14

14a. Letter of recommendation

This form should be returned by the applicant with all other application material This section is to be completed by the applicant Name of applicant Signature of applicant This section is to be completed by the recommender How long have you known the applicant? In what capacity have you known the applicant? Based on your experience, rate the applicant in the following areas vis--vis persons of similar academic and professional standing
Truly exceptional (Top 2%) Exceptional (Top 10%) Very good (Top 25%) Good (Middle 50%) Below average (Lower 25%) Cant say

Initiative Flexibility Maturity compared to peers Oral communication skills Written communication skills Ability to work with others Ability to accept constructive feedback and learn from the same Ability to understand others viewpoints Ability to finish work in time Self confidence Leadership 15

Please fill out the following information and/or write a letter of recommendation Please describe the particular talents, strengths, and weaknesses of the applicant. If you have worked with the applicant on any type of special project, please give an evaluation of his/her performance. Please indicate any favorable or unfavorable indications of the applicants leadership potential and his/her ability to do work independently. Please include any additional information that you believe is relevant. Use extra sheets if necessary

Name of Recommender

Signature of Recommender

Date 16

14b. Letter of recommendation

This form should be returned by the applicant with all other application material This section is to be completed by the applicant Name of applicant Signature of applicant This section is to be completed by the recommender How long have you known the applicant? In what capacity have you known the applicant? Based on your experience, rate the applicant in the following areas vis--vis persons of similar academic and professional standing
Truly exceptional (Top 2%) Exceptional (Top 10%) Very good (Top 25%) Good (Middle 50%) Below average (Lower 25%) Cant say

Initiative Flexibility Maturity compared to peers Oral communication skills Written communication skills Ability to work with others Ability to accept constructive feedback and learn from the same Ability to understand others viewpoints Ability to finish work in time Self confidence Leadership

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Please fill out the following information and/or write a letter of recommendation Please describe the particular talents, strengths, and weaknesses of the applicant. If you have worked with the applicant on any type of special project, please give an evaluation of his/her performance. Please indicate any favorable or unfavorable indications of the applicants leadership potential and his/her ability to do work independently. Please include any additional information that you believe is relevant. Use extra sheets if necessary

Name of recommender

Signature of recommender

Date

18

15. Application submission

Please send the downloaded application form duly filled in and signed along with GMAT score, two recommendation letters, relevant attested/notarised documents and application fee, in the form of Bankers Cheque/Demand Draft drawn in f avour o f Indian I nstitute o f M anagement C alcutta pay able at K olkata, I ndia, w ithin 31st August, 2011 to t he following address : PGPEX Office Indian Institute of Management Calcutta Diamond Harbour Road, Joka Kolkata 700 104 India E-Mail: pgpex@iimcal.ac.in Tel : +91-33-2467-8300-06 ( Extn-201 ) Fax : +91-33-2467-6629 Incomplete applications r eceived within due date will b e rejected. T he institute also will not b e l iable or will not bear any responsibility in case of any postal delay or any other factor which may result in the application

not reaching the institute within the due date.

The completed application form should reach Indian Institute of Management Calcutta by 31st August, 2011

16. Disclaimer and Signature

I certify that the information provided in this application is true and complete to the best of my knowledge. I understand that in case an offer of admission is made to me and subsequently, during or prior to commencement of the course, any information provided is found to be incorrect or false, then the Institute reserves the right to withdraw the offer or cancel my candidature.

Signature of candidate

Date

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