Registration Form - IIM Shillong

Rajiv Gandhi
Indian Institute of Management Shillong
PGP: 2013–15
Registration Form
Name: ______________________________________________________
(First Name) (Middle Name) (Last Name)
(UseBLOCK letters only)
Paste your
Photograph here
Father’s / Guardian’s Name:_____________________________________
Mother’s Name_______________________________________________
Date of Birth:
(d d) (m m) ( yyy y)
Age in Completed Years:
Gender: Male Female Blood Group:……………
Religion:________________ Marital Status: Single Married
Category: General SC ST OBC PWD
Address for Communication:__________________________________________________
______________________________________________________________________________
District ___________________ State: ______________________
Pin Code: ___________
Telephone No: ___________________
E-mail id: ______________________________
Address (Permanent Residence):_______________________________________________
______________________________________________________________________________
District ___________________ State: ______________________
Pin Code: ___________
Telephone No: ___________________
E-mail id: ______________________________
Emergency Contact No: ………………………………..
1

Educational Qualifications (starting from 10 th Standard onwards)
Name of the
Examination
Board / Institute /University
Academic
Stream
Grade/ % of
marks
obtained
(either
CGPA/GPA)
Division
/ Class
(mention
if rank
holder)
SSC/Std. X
HSSC / Std. XII
Bach. Degree
Master Degree
(if any)
Professional
Degree
(if any)
Professional Experience (start with most recent)
Name of the
organization
Location
Designation
JobProfile
Compensation
(total gross
emoluments
per month )
Work
experience
(in months)
I do hereby declare that the information furnished aboveis true to the best of my knowledge. I also
understand that if any of the above information are found to be incorrect my candidature is liable to be
terminated with immediate effect.
Place:
Date:
Signature of the Participant
2

The following are the original documents which need to be produced during the registration day.
The Original and their Photocopies needs to be arranged separately, strictly according to the
following order.
Sl. No.
1 Mark sheet & Pass Certificate for SSC.
2 Mark sheet & Pass Certificate for HSC.
Documents
3 Mark sheets (semester wise/year wise & the final mark sheet) for Bachelor Degree.
4 Bachelor Degree passing Certificate / Provisional Degree Certificate
5 Mark sheets (year wise & final) for Master Degree ( if applicable)
6 Master Degree passing Certificate / Provisional Certificate
7 Mark sheets for Professional Degree with passing certificate (if applicable)
No. of
Copies
8 Work Experience Certificate (if applicable)
9 Releasing Letter from current employer
10 Payslip of last three months
11 Resignation Letter
12 Annexure I (if applicable)
13 Annexure II
14 Annexure III
15 Annexure IV
16 Document V
17 Document VI
18 Document X
19 03 Colour Passport Size Photograph