APPLICATION FORM

MBA: 2011-13

KIIT School of Management

K I I T U n i v e r s i t y, B h u b a n e s w a r
 INDEX NUMBER

FOR OFFICE USE ONLY

KIIT School of Management

Affix your
KIIT University passport size
photograph
Bhubaneswar
www.ksom.ac.in
APPLICATION FORM
FOR
2 YEAR FULL TIME RESIDENTIAL MBA PROGRAMME

INSTRUCTION : Fill in the application form in your own handwriting clearly and legibly. Incomplete form may be rejected.

SECTION A Preference

Mark your order of preference for Centre for Group Discussion & Personal Interview (GD & PI)

Choice of GD & PI Centre

Bangalore Bhubaneswar Delhi Kolkata Mumbai

SECTION B General Information

(Please leave one box blank between two words)

1. Name of the Candidate

(in block letters)

2. Father’s/ Guardian’s Name

3. Date of Birth

D D M M Y Y Y Y
4. Address for Correspondence (in block letters)

PIN CODE

5. E-mail Address

Tel. No.
(With STD Code). Mobile No.
6.Mother’s Name ..................................................................................................................................................................................

7.Gender (Tick whichever is applicable) Male Female

8. Marital Status.................................................................................

9. Category (Tick whichever is applicable) General OBC SC ST

10. Nationality ........................................................................................................................................................................................

11. If Physically handicapped (Tick) Yes ...................................... No ................................

If Yes, please state the nature of handicap ........................................................................................................................................

SECTION C Education & Experience

12. Educational details

Name of the Board/ Name of the College/ Year of Stream Class % of

Examination University Institute Passing Marks

*
i. Matriculation/
Secondary School
Examination

ii. +2/Higher Secondary/

Equivalent

iii. Degree

. Please indicate,
if you have appeared in
any Degree exam.
and result not
declared

iv. Post Graduate

Degree, specify if any.

* : % of marks in aggregate.

13. Work Experience (In chronological order, Attach separate sheet, if necessary)

Designation Name of the Organization Period of Service Nature of the Job /

from (date) to (date) Gross Salary Per Month
SECTION D Other Information

14. Details of CAT / MAT / XAT / KIITEE

Examination : CAT, MAT, XAT KIITEE

ID/ Regn. No / Roll No.:....................................................................Composite score/ Percentile........................................................

15. Please state briefly, why you have chosen to take up management as a career (not exceeding 60 words)
..........................................................................................................................................................................................................
...........................................................................................................................................................................................................
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16. If you have represented in any sports at State/National level, give details ........................................................................................
17. Occupation
Father ........................................................................................................ Mother ...........................................................................
18. Total Annual Income of the household (gross) ....................................................................................................................................
19. Are you planning to avail study loan for the course ? Yes ........................ No ........................................
20. In case of emergency, we can contact Mr/Ms/Mrs ............................................................................................................................
Residence (phone no) ........................................ Office (phone No.) ..................................... Relationship with you ......................
21. Details of apllication fee paid : Drawee Bank .............................. DD No.......................................... Date .......................................

DECLARATION
I certify that the information furnished in this application are true to the best of my knowledge. My application may be rejected and
admission shall be cancelled if any information provided herein is found to be incorrect at any time even after admission.

Place :
Date :
Signature of the Candidate (in full)

Please enclose the copies of the following documents and tick in the corresponding boxes.

1. High School Certificate and Mark sheet.

2. +2/HSC Certificate and Mark sheet
3. Graduation (B.A,B.Com, B.Sc, Engineering etc.) Certificate and Mark sheet
4. Caste certificate, if applicable
5. Physically handicapped certificate, if applicable
6. Sports participation certificate, if applicable
7. MAT/ CAT/ XAT / KIITEE Score card
8. College Leaving Certificate
9. Migration Certificate
10. Conduct Certificate
11. Any other, Please Specify
Total no of documents attached
 FOR OFFICIAL USE

Mr/Ms ................................................................................................................................... has been selected / waitlisted in the

interview held on........................................................................ for MBA Programme at .............................................. Campus.

PAYMENT DETAILS

Fee Due Date Payment Date Amount DD. Number DD Date Bank

Confirmation

Admission
(1st Installment)

Admission Permitted / Not Permitted

Admission Officer Coordinator, Admissions Director

Completed application form along with the enclosures should reach

Admissions Office,
KIIT School of Management, Krishna Campus-7
KIIT University, Bhubaneswar- 751024, Odisha , India,
Phone: + 91-674- 2725007(D), Fax: 91-674-2725007, 2725278, 9937085344 (M)
E-mail: [email protected], Website : www.ksom.ac.in