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Personal Details

Name of Candidate:

Father's/Husband's/Guardian'sName :

Mother's Name:

Date of Birth: Candidate Gender:

Category: State/Union Territory of

Caste/Tribe:

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Caste/Tribe Name:

Nationality:

Other Nationality:

Person with Disability/DifferentlyAbled (PWD/DA):

PWD/DA Category:

Disability Percentage: Do you require wheelchair

support at the test centre?:

Communication Address

Address :

State/Union Territory: Other State/Union Territory:

Country: Other Country:

City:

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Other City With Other Country:

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Exam Centre City Preferences

Preferred City 1:

Preferred City 2:

Preferred City 3:

Preferred City 4

444602

Indian

India

Pune

Mumbai

Amravati

Nagpur

No

Shashibhushan Agrawal

01/Jun/1994

Kalpana agrawal

5096072

imsidagarwal@gmail.com

Male

8237236898

Amravati

General

MAHARASHTRA

SIDDHARTH AGRAWAL

Mangilal plot,anupam appartment,camp road,amravati

Academics Details

SSC/10th Std/Equivalent Details

Aggregate marks:

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Maximum Marks :

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Other Board Name:

HSC/12th/Equivalent/Diploma Course Details

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Other Board Name:

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Discipline:

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Bachelor Degree Details

Are you in the final year of Bachelor Degree?

Have you completed BachelorDegree?

Total Duration of Degree:

Current Semester: Aggregate Marks:

Type of University/Institution:

Other Type of University/ Institution:

State/Union Territory WhereUniversity is Situated:

Other State/UnionTerritory Where University is Situated:

University Name:

Other University Name:

Name Of College:

Degree Name:

Other Degree Name:

Discipline:

Other Discipline Name:

Month/Year of CourseCommencement:

Month/Year of Completion:

Semester-7

Computer Science

600

Prof Ram Meghe Institute Of Technology And Research

March

HSC

550

Computer Science

Sant Gadge Baba Amravati

June 2016

4 Year

Private University

B.E

510

Maharashtra State Board of Secondary and Higher Secondary Education

201092.73

Maharashtra

2012

57.41

2012

Maharashtra State Board of Secondary and Higher Secondary Education

August

March

Yes

466

77.67

Other Professional Degree Details

Have you completed any professional degree such as CA/CS/ICWAwithout completing Bachelor's Degree:

Specify Other ProfessionalDegree:

Professional Inter Marks: Professional Final Marks:

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Master Degree Details

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Type of University/Institution: Other Type of

University/Institution:

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University Name:

Other University Name:

Name of College/Institution:

Degree Name:

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Discipline:

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Month/Year of CourseCommencement:

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Work Experience Details

Automobiles/Auto-ancillaries

Banking/Financial Services

Durables

Engineering/Industrial

Fast Moving Consumer Goods(FMCG)

Information Technology

Pharmaceuticals/Healthcare

Retail

Telecommunications

Others1 (Work Area)

Others1 (Exp In Month)

Others2 (Work Area)

Others2 (Exp In Month)

Others3 (Work Area)

Others3 (Exp In Month)

Total Work Experience (In Months) 0

No

No

Programme Details

IIM Ahmedabad PGP (Interview City 1)

IIM Ahmedabad PGP (Interview City 2)

IIM Ahmedabad PGP-FABM

IIM Ahmedabad FPM

IIM Amritsar PGP

IIM Bangalore PGP

IIM Bangalore PGP EM

IIM Bangalore PGP PM

IIM Bangalore FPM

IIM Bodh Gaya PGP

IIM Calcutta PGP PGDM

IIM Calcutta FPM

IIM Indore PGP Programme IIM Indore PGP

Mumbai

IIM Indore EPGP

IIM Indore FPM

IIM Kashipur PGP

IIM Kashipur EPGPM

IIM Kashipur EFPM

IIM Kashipur FPM

IIM Kozhikode PGP

IIM Kozhikode FPM

IIM Lucknow PGP

IIM Lucknow PGP ABM

IIM Lucknow PGPSM

IIM Lucknow FPM

IIM Nagpur PGP

IIM Raipur PGP

IIM Raipur PGPWE

IIM Raipur EFPM

IIM Raipur FPM

IIM Ranchi PGDM

IIM Ranchi PGDHRM

IIM Ranchi FPM

IIM Rohtak PGP

IIM Rohtak EPGP

IIM Rohtak FPM

IIM Sambalpur PGP

RGIIM Shillong PGP

RGIIM Shillong PGPEX

RGIIM Shillong FPM

IIM Sirmaur PGP

IIM Tiruchirappalli PGP

IIM Tiruchirappalli PGPBM

IIM Tiruchirappalli PGPHRM

IIM Tiruchirappalli FPM

IIM Udaipur PGP

IIM Udaipur FPM

IIM Visakhapatnam PGP

Lucknow

Delhi

Delhi

Trichy

Raipur

Delhi

Delhi

Raipur

Raipur

Delhi

Delhi

Kolkata

Shillong

Delhi

Delhi

Bangalore

Delhi

Kashipur

Ranchi

Delhi

Delhi

Delhi

Rohtak

Delhi

Kozhikode

Delhi

Shillong

Delhi - NCR

DelhiMumbai

Delhi

KashipurKashipur

Delhi

Chennai

Delhi - NCRDelhi - NCR

Delhi

Delhi

Delhi

Bangalore

Indore

Delhi

Ahmedabad

Delhi

Udaipur

Chennai

Delhi

DECLARATION

I hereby certify that the particulars given by me in this Application Form are true to my knowledge and belief. I certify that I fulfill the CAT 2015 eligibility criteria and undertake to produce original documents whenever necessary and I will not demand any reschedule of exam. I understand all disputes will be subject to territorial jurisdiction of city of Ahmedabad only.

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