Shri Dharmasthala Manjunatheshwara nstitute for anagement evelopment I M D Affix No. 1, Chamundi Hill Road, Siddarthanagar Post, Mysore – 570011,Karnataka, India. Phone :91-821-2429722/2429161,Fax: 91-821-2425557, Website: www.sdmimd.ac.in photograph
Application Form: PGDM 2016-18
USE BLOCK LETTERS Application No. Name Parent Name Registration No. CAT/XAT/GMAT /CMAT
Date of Birth D D M M Y E A R GENDER M / F Passport No / Voter id No./Aadhar Card No / Driving Licence No./PAN Card No. SKYPE ID (Mandatory) Address for Correspondence :
City PIN State Parent/Guardian Name & Contact No: Applicant’s Mobile No : Email id (Registered with CAT /XAT/Others)
Academic Details Specify CBSE/ICSE/State/Others Name of Marks (%) / Specialization Year of Examination Degree Grade Point Passing th 10 / Matriculation NA NA
II PUC / +2 / Intermediate NA NA
Degree Final / Cumulative Marks
Post-graduation/Others (if applicable) Work Experience in months (if applicable): Application form payment Coaching Centre Name & Branch : details (if form purchased through Coaching Centre) (Application Fee Rs. 1000/-) RTGS / NEFT UTR No / Through SDMIMD website (for payment made through bank transfer- email should be sent to [email protected] giving the transfer details) D.D. / Multicity Cheque No. Date : Bank : E-remittance: HDFC Bank, Saraswathipuram Branch, Mysore, SB A/C :00651450000156, IFSC Code : HDFC0000065 AXIS BANK LTD., V.V.MOHALLA BRANCH, MYSORE, SB A/C. : 912010058973773, IFSC CODE : UTIB0000151 D.D. / Multicity Cheque should be in favour of The Director, SDM Institute for Management Development, Payable at Mysore Preference for Interview Centre (1,2,3) – Interviews to be held in February – March 2016 (SKYPE interview will be held only in specific case at the discretion of the Institute)
Ahmedabad Bangalore Bhopal Cochin Chennai Hyderabad
Kolkata Lucknow Pune Mysore Mumbai New Delhi DECLARATION: I hereby state that all the above details are true to the best of my knowledge and I will produce proof as relevant if asked.
Place : Date : Signature of the Candidate