Application Form

User Id: 7060831

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

Personal Details

Name of Candidate: BIPRO NARAYAN HABISYASI

Father's/Husband's/Guardian's
Suvro Habisyasi
Name :

Mother's Name: Chitra Habisyasi

Date of Birth: 17/Mar/1996 Candidate Gender: Male

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

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

Nationality: Indian Aadhar Card Number : 598350402907

Do you belong to Persons with
Disability(PwD) category as per No PwD Category:
RPwD Act 2016
Would you be requiring the Do you require wheelchair
Zoom Feature for the Test?: support at the test centre?:
Would you be using a scribe for
the Test?:

Specific query on PwD Support:

Communication Address
P-72 Senhati Colony

Address:
Behala

Country: India

State/Union Territory: WEST BENGAL Other State/Union Territory:

District: Kolkata Other District:

Town/City: Kolkata Pin Code: 700034

Mobile Number: 9163755819 Email Address: [email protected]

Mobile Number (Alternate) : 9831875798 Email Address (Alternate) :

[email protected]
Exam Centre City Preferences
Preferred City 1: Kolkata

Preferred City 2: Howrah

Preferred City 3: Kalyani

Preferred City 4 Hooghly

Academics Details

SSC/10th Std/Equivalent Details

Aggregate marks: 89 Month/Year of Completion: May 2012

Total Marks Obtained : 623 Maximum Marks : 700

SSC/10th Std/Equivalent Board Council for Indian School Certificate Examination

Name

HSC/12th/Equivalent/Diploma Course Details

Course Type: HSC Aggregate Marks: 75.67
Total Marks Obtained: 454 Maximum Marks: 600

12th/Equivalent Board Name: Council for Indian School Certificate Examination

Duration of Diploma Course:

University/Board/Other Authority
Name:

Discipline: Science

Month/Year of Course
Month/Year of Completion: May 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: 4 Year
Degree?
Current Semester: Semester-7 Aggregate Marks: 75.1

Type of University/Institution:
State University

State/Union Territory Where West Bengal

University is Situated:
First Bachelor Degree Details

University Name: West Bengal University of Technology

Name Of College: Neotia Institute of Technology Management and Science

Degree Name: BTECH

Discipline: Engineering/Technology

Month/Year of Course Probable Month/Year OR

July 2014 July 2018
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
Month/Year of
Commencement:
Completion:
Other Professional Degree Details
Have you completed any professional degree such as CA/CS/ICWA
No
without completing Bachelor's Degree:

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 1

Fast Moving Consumer Goods

Information Technology
(FMCG)

Pharmaceuticals/Healthcare Retail

Others
Telecommunications

Total Work Experience (In 1

months as on 31st July 2017)

Programme Details

Programme Names Interview City Selected / Not

IIM Ahmedabad PGP

(Interview City 1) Kolkata Selected

IIM Ahmedabad PGP

Bangalore Selected
(Interview City 2)

IIM Ahmedabad EPGP

(Interview City 1
Ahmedabad Selected
IIM Ahmedabad EPGP
(Interview City 2 Kolkata Selected

IIM Ahmedabad PGP-FABM Kolkata Selected

IIM Ahmedabad FPM Ahmedabad Selected

IIM Amritsar PGP Selected

Amritsar
IIM Bangalore PGP Bangalore Selected

IIM Bangalore PGP EM Bangalore Selected

IIM Bangalore PGP PM Bangalore Selected

IIM Bangalore FPM Bangalore Selected

IIM Bodh Gaya PGP Bangalore Selected

IIM Calcutta PGP PGDM Kolkata Selected

IIM Calcutta FPM Kolkata Selected

IIM Indore PGP Kolkata Selected

IIM Indore PGP HRM Kolkata Selected

IIM Indore EPGP Kolkata Selected

IIM Indore FPM Indore Selected

IIM Jammu PGP Kolkata Selected

IIM Kashipur PGP Kolkata Selected

IIM Kashipur EPGP Dehradun Selected

IIM Kashipur EFPM Kashipur Selected

IIM Kashipur FPM Kashipur Selected

IIM Kozhikode PGP Kolkata Selected

IIM Kozhikode FPM Kozhikode Selected

IIM Lucknow PGP Kolkata Selected

IIM Lucknow PGP ABM Kolkata Selected

IIM Lucknow PGPSM Kolkata Selected

IIM Lucknow FPM Lucknow Selected

IIM Nagpur PGP Kolkata Selected

IIM Raipur PGP Kolkata Selected

IIM Raipur PGPWE Raipur Selected

IIM Raipur EFPM Raipur Selected

IIM Raipur FPM Raipur Selected

IIM Ranchi PGDM Kolkata Selected

Kolkata Selected
IIM Ranchi PGDHRM

IIM Ranchi FPM Ranchi Selected

IIM Rohtak PGP Kolkata Selected

IIM Rohtak EPGP Kolkata Selected

IIM Rohtak EPGPX Selected

Kolkata

IIM Rohtak FPM Rohtak Selected

IIM Sambalpur PGP Kolkata Selected

RGIIM Shillong PGP Kolkata Selected

RGIIM Shillong PGPEX To be decided Later Selected

RGIIM Shillong FPM Shillong Selected

IIM Sirmaur PGP Kolkata Selected

IIM Tiruchirappalli PGP Kolkata Selected

IIM Tiruchirappalli PGPBM Chennai Selected

IIM Tiruchirappalli FPM Trichy Selected

IIM Udaipur PGP Kolkata Selected

IIM Udaipur FPM Udaipur Selected

IIM Visakhapatnam PGP Kolkata Selected

Payment Details

Payment Mode Amount Payment Status Payment Transaction Number Order ID

online 1800.00 S JAXG5601631276 706083120170821211210160

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 2017 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 2017 application & scores. I understand that all disputes will be subject
to the territorial jurisdiction of city of Lucknow only.
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