Name of the Candidate: ________________________

CAT 2015/GMAT Registration No.: _________________________

Shortlisted for WAT & PI (please tick relevant fields): [ ] PGP Indore [ ] PGP Mumbai

Interview Form
PGP 2016-18 Batch Admissions
(Do not send this form to Admissions Office. To be submitted during WAT and PI only)

Indian Institute of Management Indore

Prabandh Shikhar, Rau Pithampur Road, Indore 453556
Madhya Pradesh, INDIA
Ph: +91-731-2439685, email: pgpadmission@iimidr.ac.in

INDIAN INSTITUTE OF MANAGEMENT INDORE

POST-GRADUATE PROGRAMME IN MANAGEMENT
COMMENCING JULY 2016
INSTRUCTIONS
1.
2.
3.
4.
5.
6.

The information sort in this form is one of the important elements for your shortlisting/selection process and
hence complete and accurate information is very important.
Incomplete or false information will adversely affect your chances of selection.
Admission granted on the basis of false and/ or misleading information will be ipso facto null and void.
In all matters relating to admission to the programme, the decision of the Institute's authorities will be final and
binding on the applicant.
No correspondence will be entertained from the applicant regarding his/ her non-selection.
It is advisable; you may take the print out of the interview form back to back in order to reduce the number of
pages.
A. PERSONAL DATA

CAT 2015 Registration No.

Name: _____________________________________________________________________
(In CAPITAL letters)
As it appears in the school leaving certificate

Gender:

Male

Female

Nationality

Transgender

Affix your recent passport

Size photo
IMPORTANT: Applicable only for candidates shortlisted for WAT & PI for both the programmes i.e. PGP at
Indore and Mumbai. Please indicate your preference for PGP at Indore and Mumbai. If you make up in final list,
Admission offers would be made based on this preference (PGP at Indore or PGP at Mumbai).
First Preference. ____________________________ Second Preference: __________________________

Category:

Others

SC

ST

Non- Creamy
OBC

(Enclose a certificate if you belong to SC, ST or Non-Creamy OBC category

Please tick the relevant box if you suffer from

any physical disability to the extent of not less
than 40% (as per the Persons with Disabilities
Act, 1995)

Date of Birth

Blindness/
Low Vision

Hearing
Impairment

Locomotor disability/
cerebral palsy

(Enclose a photocopy of the certificate issued by a competent medical authority)

Age as on 30 June 2016 in completed years

Day

Marital status Single

Month

Years

Year

Married

Write the name of the State/UT

of your permanent residence

Annual Family Income (in Rs.)

Tel.(R):

Tel.(O):

Email:

B. ACADEMIC QUALIFICATIONS
A.

Provide complete information on examination marks in all columns. Marks stated in these columns MUST MATCH those
in the original mark sheets.

B.

Wherever you have received letter grades or grade points instead of marks, provide equivalent marks and attach a
certificate from Registrar/ Principal/ Head of the Department 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.
1.

Marks/Grades obtained in X Std/ XII Std/ Equivalent Examination(s): Fill in only if it is a Board or University
Examination

Standard

X
Std
Secondary/
Equivalent

Name of Board/ University

Year

Max. Marks
/Grade

Marks/Grade
Obtained

% Marks /
Grade
Obtained

Class/
Division/
Rank*

XI Std / Higher
Secondary/
Equivalent #
XII Std / Higher
Secondary
/
Equivalent
# Write Not applicable if there is no board examination in XI Std
*Please produce certificates/ evidence if a rank is mentioned.

1.1 Marks/Grades
Examination
Standard

obtained in X Std/ Equivalent Examination(s):

Subject

Name of the subject

Fill in

only if it

is a Board or

Max Marks/
Grade

Marks/ Grade
obtained

University
No of
attempts

Sub.1
X Std / Secondary /
Equivalent

Sub.2
Sub.3

Month and Year of

passing

Sub.4
Sub.5
Sub.6
Sub.7
Sub. 8
Sub. 9
Sub. 10
Total

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

1.2 Marks/Grades obtained in XII Std/ Equivalent Examination(s): Fill in only if it is a Board or University
Examination
Standard

Subject

Name of the subject

Max Marks/
Grade

Marks/ Grade
obtained

No of
attempts

Sub.1
XI Std
/ Higher
Secondary/
Equivalent #

Sub.2
Sub.3
Sub.4

Month and Year of

passing

Sub.5
Sub.6
Sub.7
Sub. 8
Sub. 9
Sub. 10
Total

XII Std / Higher

Secondary/
Equivalent

Sub.1
Sub.2
Sub.3
Sub.4

Month and Year of

passing

Sub.5
Sub.6
Sub.7
Sub. 8
Sub. 9
Sub. 10
Total

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

# Write Not applicable if there is no board examination in XI Std

2. Bachelor's Degree Examination

Name of the Degree (B.A., B.Tech., B.Sc., MBBS, BDS etc.)

_________________________________

Discipline (Engineering, Arts, Science, Law etc.)

_________________________________

Subject Specialization (Mechanical, Computer Sci., Literature, etc.)

_________________________________

Name of the College/Institution

_________________________________

Name of the University

_________________________________

Mode of Study (Full-time, Part-time, Distance education, etc.)

_________________________________

Duration of your graduation degree course

3 yrs

4 yrs

5 yrs

If you have already completed the Bachelor's degree examinations, please mention the following details as per total
marks/ grades obtained across all semesters/years of Bachelor Degree.
Month & Year of Exam

Max. Marks/ GPA

Marks/ GPA
Obtained

% of Marks
Obtained

Class/ Division

If you have already completed the Bachelor's degree examinations and percentage of marks considered by the
University for awarding degree is different, please mention the following details as per the University policy
(you should submit a proof of the university policy)
Month & Year of Exam

Max. Marks/ GPA

considered for
awarding Degree

Marks/ GPA
Obtained as per
university policy

% of Marks
Obtained as per
university policy

Class/ Division

If you have NOT completed the Bachelor's degree examinations, please mention the following and also bring the
prescribed certificate from the Institute or College or University as given on our website.

If you are appearing for the final semester/year Bachelor's degree exam, indicate month and year of examination and
mention your marks obtained up to pre-final semester/year*

Expected Month &

Year of Exam

Max. Marks/ GPA up to

pre-final semester/year

Marks/ GPA Obtained up

to pre-final semester/year

% of Marks
Obtained

Class/ Division

In the Table below, mention details of marks obtained by you in examinations of all subjects (including
optional, subsidiary, internal, elective, minor, languages, practical etc.) taken in each semester/year of the
Bachelor's degree irrespective of whether these marks are considered for granting class/ division by the
university/ institute.
Semester/ Year

Subject

Name of the subject

Max
Grade

Marks/

Marks/
obtained

Grade

No of
attempts

Sub.1

First Semester / 1

st

Sub.2
Year
Sub.3
Sub.4
Sub. 5

Month and
Year of
passing

Sub.6
Sub.7
Sub. 8
Sub. 9
Sub. 10
Total
Sub.1

Second Semester / 1
Year

st

Sub.2
Sub.3
Sub.4
Sub.5

Month and
Year of
passing

Sub.6
Sub.7
Sub. 8
Sub. 9
Sub. 10
Total

Semester/ Year

Subject

Name of the subject

Max
Grade

Marks/

Marks/
obtained

Grade

No of
attempts

Sub.1

Third Semester / 2
Year

nd

Sub.2
Sub.3
Sub.4
Sub. 5

Month and
Year of
passing

Sub.6
Sub.7
Sub. 8
Sub. 9
Sub. 10
Total
Sub.1

Fourth Semester / 2
Year

nd

Sub.2
Sub.3
Sub.4
Sub.5

Month and
Year of
passing

Sub.6
Sub.7
Sub. 8
Sub. 9
Sub. 10
Total

Semester/ Year

Subject

Name of the subject

Max
Grade

Marks/

Marks/
obtained

Grade

No of
attempts

Sub.1
rd

Sub.2

Fifth Semester / 3 Year

Sub.3
Sub.4
Sub. 5
Month and
Year of
passing

Sub.6
Sub.7
Sub. 8
Sub. 9
Sub. 10
Total
Sub.1

rd

Sub.2

Sixth Semester / 3 Year

Sub.3
Sub.4
Sub.5
Month and
Year of
passing

Sub.6
Sub.7
Sub. 8
Sub. 9
Sub. 10
Total

Semester/ Year

Subject

Name of the subject

Max
Grade

Marks/

Marks/
obtained

Grade

No of
attempts

Sub.1

Seventh Semester / 4
Year

th

Sub.2
Sub.3
Sub.4
Sub. 5

Month and
Year of
passing

Sub.6
Sub.7
Sub. 8
Sub. 9
Sub. 10
Total
Sub.1

Eighth Semester / 4
Year

th

Sub.2
Sub.3
Sub.4
Sub.5

Month and
Year of
passing

Sub.6
Sub.7
Sub. 8
Sub. 9
Sub. 10
Total

Semester/ Year

Subject

Name of the subject

Max
Grade

Marks/ Marks/
obtained

Grade

No of
attempts

Sub.1

Ninth Semester / 5
Year

Sub.2

th

Sub.3
Sub.4
Sub. 5

Month and Year

passing

of

Sub.6
Sub.7
Sub. 8
Sub. 9
Sub. 10
Total
Sub.1

Tenth Semester / 5
Year

th

Sub.2
Sub.3
Sub.4
Sub.5

Month and Year of Sub.6

passing
Sub.7
Sub. 8
Sub. 9
Sub. 10
Total
Grand Total of Bachelors Degree)
Space for explanation of letter grades / grade points/ any other relevant information relating to academic qualification

10

3.

Post- Graduate Examination

Title of Degree:

Specialization:

Name of University/ Institute attended

Semester/ Year

Subject

Name of the subject

Max Marks/
Grade

Marks/ Grade
obtained

No
of
attempts

Sub.1

First Semester / 1
Year

th

Sub.2
Sub.3
Sub.4
Sub.5

Month and Year of

passing

Sub.6
Sub.7
Sub. 8
Sub. 9
Sub. 10
Total
Sub.1
Sub.2

Second Semester /
st
1 Year

Sub.3
Sub.4
Sub.5

Month and Year of

passing

Sub.6
Sub.7
Sub. 8
Sub. 9
Sub. 10
Total

11

Semester/ Year

Subject

Name of the subject

Max Marks/
Grade

Marks/ Grade
obtained

No
of
attempts

Sub.1

Third Semester / 2
Year

Sub.2

nd

Sub.3
Sub.4
Sub.5

Month and Year of

passing

Sub.6
Sub.7
Sub. 8
Sub. 9
Sub. 10
Total
Sub.1
Sub.2

Fourth Semester
nd
2 Year

/
Sub.3
Sub.4
Sub.5

Month and Year of

passing

Sub.6
Sub.7
Sub. 8
Sub. 9
Sub. 10
Total

Grand Total of Masters Degree

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

12

4.

Post-Graduate Professional Examination

Give details of the last professional examination you have taken (e.g. CA, ICWA, CS, Law, Medicine etc.)
University/ Institute registered with: _________________________________________________________

Name of the course of study (such as CA, ICWA, CFA, Medicine etc):___________________________________
Semester/ Year

Subject

Name of the subject

Max Marks/
Grade

Marks/ Grade
obtained

No
attempts

Sub.1

First Semester / 1
Year

th

Sub.2

Sub.3

Sub.4
Month and Year of
passing
Sub.5

Sub.6

Sub.7

Sub. 8

Total

Sub.1

Second Semester /
st
1 Year

Sub.2

Sub.3

Sub.4
Month and Year of
passing
Sub.5

Sub.6

Sub.7

Sub. 8

Total

13

of

Semester/ Year

Subject

Name of the subject

Max Marks/
Grade

Marks/ Grade
obtained

No
attempts

Sub.1

Third Semester / 2
Year

nd

Sub.2

Sub.3

Sub.4
Month and Year of
passing
Sub.5

Sub.6

Sub.7

Sub. 8

Total

Sub.1

Forth Semester / 2
Year

nd

Sub.2

Sub.3

Sub.4
Month and Year of
passing
Sub.5

Sub.6

Sub.7

Sub. 8

Total

Grand Total of Professional Examination

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

14

of

C. ACADEMIC CAREER

a)

Scholastic Achievements
Please list scholastic awards or scholarships conferred on you. Please bring the certificates in support of the same.

b)

Please describe your strengths and weaknesses that you have identified in yourself as a student.

15

D. EMPLOYMENT RECORD (ONLY UP TO July 31, 2015)

Mention ONLY full-time, paid work experience after Bachelor's degree.
Do not include training/ project work done as an integral part of any curricular requirement.
Organization

Designation

Joining
date

Leaving
date

Monthly
Remuneration (Rs.)

Reasons for leaving

In your present/ last job, briefly describe your job responsibilities, achievements and failures.

E. DISCONTINUITY IN CAREER
If work experience and academic/ professional qualifications do not account for the entire period from the time you
completed the 10th standard till date, please specify the time gaps, with full explanation.

16

F. CAREER PLANS
Why do you wish to go in for a management career?

Besides management education, which area/ field would interest you most for a career and/ or for further education?

G. EXTRA-CURRICULAR ACTIVITIES
Please give details about your accomplishments, awards received and position held (a) in sports, games, and hobbies, (b) in
associations and voluntary organizations. (Please show original certificates to the Interview panel members.)

17

H. 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. (The information given here will be held under strict confidence).

If you have suffered from any chronic illness, including mental illness, in the past, please provide details below:
Nature of illness

Period of illness

Date of completion
of treatment

Remarks, if any

1.
2.
3.

I. 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
Institute including the submission of a certificate at the time of registration from Principal/ Registrar of my college/ institute
that except for declaration of results, I have completed all requirements for obtaining the Bachelor's degree. And that I would
have to produce evidence (mark sheet/ certificate) of having passed the Bachelor's Degree on or before December 31,
2016. Non-fulfilment of these requirements will automatically result in the cancellation of the provisional admissions offer.
However, appearing for the qualifying degree examination should be completed before June 30, 2016.
I certify that the particulars given by me in this interview form 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 for the programme.

Place: ______________________
Date: _____________________

__________________________
Signature of the candidate

Enclosures required:
1. Attested copies of all academic mark sheets and certificates.
2. Attested copy of caste/tribe certificate if you are Scheduled Caste / Scheduled Tribe candidates.
3. Attested copy of caste/community certificate if you belong to Non-Creamy Other Backward Class (of current
financial year).
4. Attested copy of the medical certificate if you are a physically challenged person (as per the Persons with
Disabilities Act, 1995).
5. Attested copy of the certificate in support of your work experience (if applicable)
6. Original Certificate from Institute or College or University (applicable for those candidates who have not
completed Bachelor Degree)
PLEASE READ THIS FORM ONCE AGAIN AND MAKE SURE THAT YOU HAVE COMPLETED ALL THE
ITEMS RELEVANT TO YOU AND HAVE FULLY COMPLIED WITH ALL REQUIREMENTS. IN CASE OF
ICOMPLETE INFOMRATION YOUR CANDIDATURE WILL BE REJECTED.

18