IIMM CMM CERTIFICATION APPLICATION FORM

Instruction to fill in the application form: 1. All the details mentioned in the form are to be responded to, in block letters. 2. Please be informed that only fully completed application forms will be eligible for screening. 3. In places where there is no relevant data, please indicate “Not Applicable / NA”. 4. Attest scanned copy of document wherever necessary. Scanned copies of the following documents are mandatory: Degree certificate and PAN card. 5. Please e-mail completed application forms with attachments to: [email protected]. Forms may also be mailed to: Deputy Chairman E-learning Indian Institute of Material Management, Bangalore # 304, 306 & 307, 'A' Wing, III Floor, Mittal Tower, No. 6, M.G. Road, Bangalore-560001. Phone: (080) 25327251/52, Fax: (080) 25327253

Payment Instructions: 1.Registration fee of Rs.5000/- waived off till 30th April 2013. The total fee for Certification is inclusive of IIMM Life membership fee worth Rs.7500/- which is applicable for deduction for existing life members. Early birds can avail concession upto Rs. 12,500/- 2. All payments should be made by DD only in favor of “IIMM NHQ collection account” payable in Mumbai. DD should be sent to: Indian Institute of Materials Management-NATIONAL HEADQUARTERS Plot Nos. 102 & 104, Sector - 15, Institutional Area CBD Belapur, Navi Mumbai - 400614 3. Payment may also be made at ICICI Bank directly to ICICI Bank Account No: 015101027881 at Vashi Branch, Navi Mumbai. In case of direct deposit, please send us the original stamped counterfoil of the pay-in-slip with details of remittance. (Kindly send scanned copies through email, of the pay-in-slip so that processing commences as soon as possible) 4. Application fees will not be refunded under any circumstances. Section – A

I would like to apply for:

Preferred location

Your details

First name

Surname

Middle name

Gender Male Female

Organisation / Residence contact details

Preferred contact address Work Home

Organisation name

Position / Job Title

Work address

Work Telephone

Work Email

Mobile

Home address

Home Telephone

Personal Email

PAN number

Passport Number Countries Visited:

Total Experience

Relevant Experience in the applied field of certification

Are you life member of IIMM?

Have you participated in IIMM events? Mention if any in last 3 years How did you know about Friends Professionals Website Others (Specify) IIMM? Section - B

EDUCATION DETAILS

(Start from graduation, post graduation and any other relevant academic certifications/Diploma)

SL NO COURSE INSTITUTION LOCATION YEAR OF PASSING REMARKS

Have you attended any Training / certification in last 3-5 years?

EMPLOYEMENT DETAILS (Start from the current organisation to previous)

SL NO ORGANISATION DESIGNATION LOCATION REPORTING TO DURATION

Describe your current organisation Structure and Team

Do you have anyone reporting Direct : Dotted:

Mention your top Five Skills and Competencies :

Current Salary Band (Upto 10L) (10L-15L) (15L-20L) (20L and above) Section – C

Have you received any Awards & Recognition in career?

1. Describe your current position and responsibility and productive indicators (KPI) in the organisation

2. Provide a brief biography that describes your career to date; include any leadership positions outside your employment (eg, public appointments, non-executive role or trusteeship).

3. Have you written any articles, white papers on the subject in last 3 years? Mention your association with relevant forums, guest lectures etc..

4. Briefly describe your reasons for applying for this Certification and how you are hoping it will help you develop as a leader.

5. How do you think you would contribute to the Material Management and Logistic group?

6. What leadership challenges do you like to face in future?

7. Mention the Trade associations you have associated with:

8. Is there any further information that you think we should have?

Section - D DECLARATION

I solemnly declare for and on behalf of that to the best of my knowledge and belief, the information given in the application form and the statements accompanying it are correct and complete. Submissions made along with application are original. I hereby promise on behalf of IIMM to abide by the Rules and Regulations of IIMM. I understand and accept that in case, at any point of time, the information furnished by me for and on behalf of IIMM found to be incorrect; the membership of IIMM is liable to be terminated without notice and without any liability on the part of IIMM. I further understand and accept that IIMM reserves the right to reject the application for membership without ascribing any reason whatsoever.

For and on behalf of

(Signature of applicant)