IN NDIAN INSTITUTE OF MA ANAGEMEN INDORE NT INTE EGRATED PR ROGRAMME IN MANAGE EMENT (IPM M)

Last date for receipt of applicat tion at IIM Indo ore: July 20, 201 12 INST TRUCTIONS This appli ication form is a key part of adm mission process and important f your selectio Complete an accurate info for on. nd ormation are extrem important. Incomplete or false information will adversely affect your chan mely f nces of selection n. 2. Admission granted on the basis of false and / or mislead informatio n will be ipso fa ding acto null and voi id. 3. In all mat tters relating to admission to th programme, the decision of the Institute's authorities will be final and bin his f nding on the applic cant. 4. No corres spondence will be entertained fr b rom the applican regarding his / her non select nt tion. 5. Please submit your appli ication so as to reach IIM Indore on or before July 20, 2012 along with atte e ested copies of relevant certificate es. 6. The application fee of Rs 1000 (Rupees one thousand only) shall be pa by DD/BC in drawn in favou of Indian Inst s. o aid ur titute of Managem ment Indore, pa ayable at Indore Remittance Det tails: Draw Bank Branch Location N Name of the Can ndidate wee 1.

RITHU SOUMYAJ
D DD/BC Date DD/ No /BC Amou (Rs.) unt

(I) PER RSONAL DATA Name of the Candidate (As given in the certificates)

RITHU SOUMYAJ
Date of Birth M Y Age as on June 30, 2012

4
SC

17 YEARS
ST

Affi your fix re ecent passp size port co olour phot tograph h here
PWD/ DA

Gender and Cat tegory (Tick the appropriate one a es) Male Female General

NC OBC C

(Ca andidates belon nging to NC OBC C/SC/ ST/PWD/D need to subm attested cop of category certificate along with this applic DA mit py cation) Name of the Pa arents/ Guardian n: Contact number t Em mail
[email protected]

P G RAVINDRAN
s: Mailing address

+919844684151

Rithu Soumyaj, C/O Mrs. Kanthimathi K, #203, Padmeshwari Nagar, Near Kamadhenu Temple, Behind RIFCO Shantiniketan, P.O Virgonagar Post.

City

BANGALORE +918025615134
Fax: F

State

KARNATAKA
Email:

PIN

560049

Phone:

[email protected]

Integrated Pro ogramme in Ma anagement at IIM Indore -Ap I pplication

A. B.

(II) ACADEMIC QUALIFICATIONS Provide complete and accurate information on examination marks in all columns. Wherever you have received letter grades or grade points instead of marks, provide equivalent marks and attach a certificate from competent authority explaining the method of conversion. Where such conversions are not possible, please provide an explanatory note in the additional space provided at the end of this page. The Admission Committee's decision in such cases would be final. Attach attested photocopies of marksheets and certificates for X Std, XI Std and XII Std to this application. If XII Std marksheets and certificate are not available, then write the reason why they are not available in the space below.

C.

Schooling: Standard Name of Board / University Year Total Max. Marks / Grade Total Marks / Grade Obtained % Marks / Grade Obtained Class / Division / Rank* Distinction

X Std / Secondary/ Equivalent XI Std / Equivalent

Central Board of Secodary Education (CBSE) Pre University Education Board, Karnataka

2010 2010

10 600 600

9.0 429 361

85.5 71.5 60.16

First Class

XII Std / Higher Pre University Education 2010 Secondary / Board, Karnataka Equivalent *Please produce certificates / evidence if a rank is mentioned.

First Class

Standard

From (Yr)

To (Yr)

Subject

Marks / Grade obtained

No of attempts

Subject

Marks / Grade obtained

No of attempts

X Std / Secondary / Equivalent

Science 2009 2010 Mathematics Social Science English Physics 2009 2009 Chemistry Mathematics Electronics

A1 A1 A2 B1 90 80 70 43 75 47 58 74

Hindi

B1

XI Std / Equivalent

English Hindi

80 66

XII Std / Higher Secondary / Equivalent

Physics 2009 2009 Chemistry Mathematics Electronics

English Hindi

60 47

Space for explanation of letter grades / grade points / any other relevant information relating to academic qualification

GRADE POINT(GP): A1 = TEN; A2 = NINE; B1 = EIGHT and so on. Cumulative Grade Point Average (CGPA) 9.0 An indicative equivalence of Grade Point and Percentage of Marks can be assessed as follows : Subject wise indicative percentage of marks = 9.5 GP of the subject Overall indicative percentage of marks = 9.5 CGPA

Integrated Programme in Management at IIM Indore -Application

(III) SAT 1 Score details SAT 1 Score Card (attach attested photocopy to this application) (SAT 1 scores obtained during January 1, 2011 July 20, 2012 are only valid) Critical Reading Section Mathematics Section

Writing Section

Overall

Choice of Center for Aptitude Test (AT) and Personal Interview (PI): AT and PI Centre Preference (Chennai / Delhi / Hyderabad / Indore / Kolkata / Mumbai) 1 2 3

Chennai

Hyderabad

Mumbai

(IV) SCHOLASTIC ACHIEVEMENTS Scholastic Achievements: Please list scholastic awards or scholarships conferred on you during your School education at Secondary and Higher Secondary or Equivalent levels, for achievements in curricular, co curricular and extra curricular activities at district, state, and national level only. Do not mention achievements that at are not at district, state, and national level. You need to attach attested copies of certificates in support of your claims to this application. Awarded certificate of distinction for achieving a state ranking of 37 in the 2nd Nation wide Interactive Science Olympiad. Represented India in the One Day International match against Sri Lanka at the 'Indo Lanka Peace Cup' as part of The International Match Exposure & Cultural Exchange Programme organized by YMCA, Bangalore. Participated in the state level 'YMCA Peace Cup', The Twenty 20 Cricket Tournament organized by YMCA as part of the Cricket For Peace campaign. Awarded 'Senior Brown Belt' in the art of Shito Ryu Karate by Ken Ei Mabuni Karate School of India, recognized by Olympic Council of Asia. Selected for the 24th Annual Summer Camp organized for training and development of promising cricketers. (V) CAREER PLANS Why do you wish to go in for a management education through the Integrated Programme in Management? (Limit your response to 100 words)

The reasons that attract me towards pursuing a management career are very personal. Ever since my brother joined IIM A and my cousin joined IIM L, I have been well exposed to the varied career possibilities and the freedom of expression that such an education offers. Both my brother and my cousin have set up their own entrepreneurial ventures and this is an inspiration for me. I want to be in an environment that is rigorous and disciplined, but at the same time innovative, challenging and conducive to fostering such a spirit in me, thus equipping me for an exciting career in management and hopefully towards starting my own venture someday. I feel the IPM would give me a great head start in this direction.

Integrated Programme in Management at IIM Indore -Application

(VI) MEDICAL HISTORY Please state whether you have any existing physical disability or any chronic illness, including mental illness, which could affect your studies at the Institute.

If you have suffered from any chronic illness, including mental illness in the past, please provide details below: Nature of illness 1. 2. 3. It is mandatory for all applicants to ensure that they are medically fit for joining the programme and they shall get the medical fitness certificate from authorised Doctor / hospital, preferably from Government Hospitals. When suffered Date of completion of treatment Remarks, if any

(VII) DECLARATION I clearly understand that if I am selected, I will be allowed to join the programme only if I satisfy all requirements of the programme including the submission of a certificate at the time of registration from Principal of my school that except for declaration of results, I have completed all requirements for obtaining XII Std / Higher Secondary / equivalent qualification and that I would have to produce evidence (mark sheet & certificate) of having passed the XII Std / Higher Secondary / Equivalent examination on or before December 31, 2012. Non fulfilment of these requirements will automatically result in the cancellation of the provisional admissions offer and no refund of fee will be made. I certify that the particulars given by me in this application are true to the best of my knowledge and belief. I understand that admission granted on the basis of false and / or misleading information will be ipso facto null and void. I agree to abide by the decision of the institute authorities regarding my selection / non selection for the programme. I also understand that commitment fee which I may pay are non refundable and no claim will be made by me or on my behalf for the same. I undertake to produce the following documents at the time of personal interview, if called for: Original and attested copies of all academic certificates, marksheets, other certificates, evidencing proof of all claims made in this application. Original and attested copy of reservation certificate in case of SC, ST and PWD/DA candidates A duly signed photocopy of this application

Place: ______________________

Date:______________________

_________________________ Signature of the applicant

PLEASE READ THIS FORM ONCE AGAIN AND MAKE SURE THAT YOU HAVE COMPLETED ALL THE DETAILS RELEVANT FOR YOU AND HAVE COMPLIED WITH ALL REQUIREMENTS. INCOMPLETE APPLICATIONS ARE LIABLE TO BE REJECTED

Send in your completed application form (not later than July 20, 2012)
To

The Admissions Office Indian Institute of Management Indore, Prabandh Shikhar, Rau-Pithampur Road, Indore 453331
Integrated Programme in Management at IIM Indore -Application 4