Application Form

User Id: 6176182

CANDIDATES ARE REQUESTED TO RETAIN THE PRINTOUT OF ACKNOWLEDGEMENT PAGE FOR FUTURE REFERENCE.

Personal Details

Name of Candidate: LALAKIYA AMULKUMAR ASHOKBHAI

Father's/Husband's/Guardian's
LALAKIYA ASHOKBHAI RAMJIBHAI
Name :

Mother's Name: PRAFULLABEN ASHOKBHAI LALAKIYA

Date of Birth: 26/Oct/1996 Candidate Gender: Male

State/Union Territory of
Category: General
Caste/Tribe:

Serial Number of caste/Tribe: Caste/Tribe Name:

Country: Indian

Person with Disability (PWD): No PWD Category:

Do you require wheelchair

Disability Percentage:
support at the test centre?:
Would you be using a scribe
Aadhar Card Number 767199634121 for the Test?

Communication Address
ASHOKBHAI LALAKIYA

Address:
LALAKIYA STREET NEAR RAM TEMPLE

WANSJALIYA

Country: India

State/Union Territory: GUJARAT Other State/Union Territory:

District: Jamnagar Other District:

Town/City: WANSJALIYA Pin Code: 360531

Mobile Number: 8758153078 Email Address: amulpatel1996@gmail.com

Mobile Number (Alternate) : 7043355859 Email Address (Alternate) : amulpatel2610@gmail.com

Exam Centre City Preferences
Preferred City 1: Anand

Preferred City 2: Ahmedabad

Preferred City 3: Vadodara

Preferred City 4 Rajkot

Academics Details

SSC/10th Std/Equivalent Details

Aggregate marks: 79.20 Month/Year of Completion: March 2011

Total Marks Obtained : 396 Maximum Marks : 500

SSC/10th Std/Equivalent Board Gujarat Secondary & Higher Education Board

Name

HSC/12th/Equivalent/Diploma Course Details

Course Type: Diploma Aggregate Marks: 80.23

Total Marks Obtained: 277 Maximum Marks: 325

12th/Equivalent Board Name:

Duration of Diploma Course: 3

University/Board/Other Authority GUJARAT TECHNOLOGICAL UNIVERSITY

Name:

Discipline:

Month/Year of Course August 2011 Month/Year of Completion: June 2014

Commencement:

First Bachelor Degree Details

Are you in the final year of Bachelor Degree? Yes

I have more than one Bachelor's Degree?

Have you completed Bachelor

Total Duration of Degree: 3 Year
Degree?
Current Semester: Semester-7 Aggregate Marks: 71.16

Type of University/Institution:
Deemed University

State/Union Territory Where Gujarat

University is Situated:

University Name: Other

Name Of College: CHANDUBHAI S. PATEL INSTITUTE OF TECHNOLOGY CHANGA

Degree Name: BE
First Bachelor Degree Details

Discipline: Others

Month/Year of Course 2014 2017

August Probable Month/Year OR May
Commencement:
Month/Year of Completion:
Second Bachelor Degree Details
Are you in the final year of Bachelor Degree?

Have you completed Bachelor Total Duration of Degree:

Degree?
Current Semester: Aggregate Marks:

Type of University/Institution:

State/Union Territory Where

University is Situated:

University Name:

Name Of College:

Degree Name:

Discipline:

Month/Year of Course Probable Month/Year OR

Commencement: Month/Year of Completion:

Master Degree Details

Do you want to enter Master No
Degree Details?

Master Degree Completion Status: Duration:

Current Semester: Aggregate Marks:

State/Union Territory of
Type of University/Institution:
University:

University Name:

Name of College/Institution:

Degree Name:

Discipline:

Month/Year of Course
Probable Month/Year OR
Commencement:
Month/Year of Completion:
Other Professional Degree Details
Have you completed any professional degree such as CA/CS/ICWA? :
No

Professional Inter Marks: Professional Final Marks:

Month/Year of Course
Month/Year of
Commencement:
Completion:

Work Experience Details

Automobiles/Auto-ancillaries Banking/Financial Services

Durables Engineering/Industrial

Fast Moving Consumer Goods

Information Technology
(FMCG)

Pharmaceuticals/Healthcare Retail

Others
Telecommunications

Total Work Experience (In months 0

as on 31st July 2016)

Programme Details

Programme Names Interview City Selected / Not

IIM Ahmedabad PGP Ahmedabad Selected

(Interview City 1)

IIM Ahmedabad PGP Mumbai Selected

(Interview City 2)

IIM Ahmedabad PGP-FABM Ahmedabad Selected

IIM Ahmedabad FPM Ahmedabad Selected

IIM Amritsar PGP Not Selected

IIM Bangalore PGP Mumbai Selected

IIM Bangalore PGPEM Bangalore Selected

IIM Bangalore PGPPM Bangalore Selected

IIM Bangalore FPM Bangalore Selected

IIM Bodh Gaya PGP Mumbai Selected

IIM Calcutta PGP PGDM Mumbai Selected

IIM Calcutta FPM Kolkata Selected

IIM Indore PGP Mumbai Selected

IIM Indore PGP Mumbai Mumbai Selected

IIM Indore EPGP Mumbai Selected

IIM Indore FPM Indore Selected

IIM Jammu PGP Mumbai Selected

IIM Kashipur PGP Mumbai Selected

IIM Kashipur EPGPM Dehradun Selected

IIM Kashipur EFPM Kashipur Selected

IIM Kashipur FPM Kashipur Selected

IIM Kozhikode PGP Mumbai Selected

IIM Kozhikode FPM Kozhikode Selected

IIM Lucknow PGP Mumbai Selected

IIM Lucknow PGP ABM Mumbai Selected

IIM Lucknow PGPSM Mumbai Selected

IIM Lucknow FPM Lucknow Selected

IIM Nagpur PGP No Interviews for this programme Selected

IIM Raipur PGP Mumbai Selected

IIM Raipur PGPWE Raipur Selected

IIM Raipur EFPM Raipur Selected

IIM Raipur FPM Raipur Selected

IIM Ranchi PGDM Mumbai Selected

IIM Ranchi PGDHRM Mumbai Selected

IIM Ranchi FPM Ranchi Selected

IIM Rohtak PGP Mumbai Selected

IIM Rohtak EPGP Mumbai Selected

IIM Rohtak FPM Rohtak Selected

IIM Sambalpur PGP Mumbai Selected

RGIIM Shillong PGP Mumbai Selected

RGIIM Shillong PGPEX Not Selected

RGIIM Shillong FPM Shillong Selected

IIM Sirmaur PGP Mumbai Selected

IIM Tiruchirappalli PGP Mumbai Selected

IIM Tiruchirappalli PGPBM Chennai Selected

IIM Tiruchirappalli FPM Trichy Selected

IIM Udaipur PGP Mumbai Selected

IIM Udaipur FPM Udaipur Selected

IIM Visakhapatnam PGP Mumbai Selected

Payment Details

Payment Mode Amount Payment Status Payment Transaction Number Order ID

online 1700 S GCTR4754698989 617618220160915134642446

DECLARATION

I have previewed the Application Form by clicking on the Preview Application Button and confirm that all the data reflecting in the Preview are correct.
I hereby certify that the information given by me in this Application Form is true to the best my knowledge. I certify that I fulfill the CAT 2016 eligibility
criteria and undertake to produce original documents whenever necessary and I will not demand any reschedule of exam. I agree to abide by the declaration
of the authorities regarding the eligibility of my application and understand that any misrepresentation or omission of facts in my application may justify
cancellation of my CAT 2016 application & scores. I understand that all disputes will be subject to the territorial jurisdiction of city of Bangalore only.

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