APPLICATION FORM - Indian Institute of Packaging

APPLICATION FORM
Two Year Post Graduate Diploma in Packaging
28 th Batch (2012 - 2014)
Form No.
Roll No. PG/ / /2012
All entries to be in block letters only.
Affix
Passport
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Photo
1. Full Name of Candidate: (as per X th passing certificate)
2. Gender: Male Female
3. Marital Status: Married Unmarried
4. Date of Birth: 5. Age: (as on 12/06/2012) 6. Nationality:
7. Father’s / Husband’s Name:
Educational Qualifications:
Occupation:
Place of Work - Address:
Tel. Office: Tel. Residence: Annual Income:
7. Mother’s Name (as per X th passing certificate):
Educational Qualifications:
Occupation:
Place of Work - Address:
Tel. Office: Tel. Residence: Annual Income:
8. Correspondence Address:
Pin
Tel.:
E-mail:
9. Educational Qualifications
Exam Passed Board / Year of Subjects Marks Obtained
University Passing (%) Total / Out of
X or Equivalent /
XII or Equivalent /
Degree BSc / BE / B Tech /
Any other /
Additional or higher qualification details may please be attached with the form.
Last date for receiving filled application form at IIP Mumbai - 12 th June, 2012
Address: E-2, MIDC Area, P. B. No. 9432, Andheri (E), Mumbai - 400 093.
Prospectus PGDP
Application Form 1 / 2

10. Whether belonging to SC ST OBC non creamy PWD General
(If applicable, please tick and provide attested copies of supporting documents as prescribed by Central Government. Original
to be shown at the time of admission.)
Admission to the course is considered subject to
l Candidate has completed both XII & degree from science stream.
l Submission of attested copies of all certificates (X, XII, degree) with the application form.
l Submission of attested copies of degree mark sheet or provisional mark sheet (as given by University) at the time of admission
interview.
11. Details of any periods of recent employments, if any
Year Position Held and Responsibility Employer’s Name and Address
12. Choice of Centre (for written test), Please tick any one
Chennai Delhi Hyderabad Kolkata Mumbai
13. Choice of Centre for undergoing the course (Please tick any one)
(Allocation of seat based on merit and availability)
1. Delhi 2. Kolkata 3. Mumbai 4. Hyderabad
15. Declaration:
l If admitted, I declare that I shall submit myself to the disciplinary jurisdiction of the authorities of the Indian Institute of
Packaging, and shall observe and abide by the rules made by the Institute. I also undertake that so long as I am a student of
the Institute, I shall not do anything inside or outside the Institute that will interfere with its orderly governance and discipline.
l I also declare that I do not suffer from any contagious disease, and have sound mental health and physical health. A
certificate for my medical fitness from a registered medical practitioner will be submitted on admission to the course.
l I know that factory visits / field studies / work is part of the course syllabus and I will undertake it at my own risk.
l I know that my admission for the course stands cancelled automatically if any of the information given above is found to
be false or untrue or partially true / unsupported with documentary proof, anytime even after admission.
Yours faithfully
(Signature of the Parent / Guardian)
(Signature of the Candidate)
Important Guidelines for Submitting of Application Form
l Application form downloaded from website it to be submitted to IIP, Mumbai along with Demand Draft of ` 500/- (Five Hundred
only) drawn in favour of Indian Institute of Packaging; payable at Mumbai, along with two self address envelope including pin code.
Important Dates
l Last date for receiving filled applications at IIP, Mumbai : 12 th June, 2012
l Written test in Mumbai, Delhi, Chennai, Kolkata and Hyderabad : 25 th June, 2012
l Display of short listed candidates at HO & Regional Centres : 20 th July, 2012
l Personal interview in Regional Centre (RC) : 23 rd to 27 th July, 2012
l Personal interview in Mumbai : 30 th July, 2012
l Final selection and display at HO and RC : 1 st August, 2012
l Admission and payment of fees : 3 rd August, 2012
l Admission and payment of fees for wait listed students : 7 th August, 2012
l Commencement of the course : 13 th August, 2012
Candidates will be required to appear for the Entrance Examination and Personal Interview at their own cost.
Prospectus PGDP
Application Form 2 / 2