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LAL BAHADUR SHASTRI BUSINESS INCUBATION CENTRE, DELHI

(In collaboration with Group Chiasma)

APPLICATION FORMGROUP CHIASMA

 No.

 Instruction for filling the Application Form:i Fill in the application form in capital letters. The form should be complete in all respects.

ii Please do not enclose any testimonials alongwith the form. All Certificates Originalsshould be produced at the time of interview.

iii Incomplete forms will not be considered.

iv Last date for receipt of completed application form is 31st March,2011.

v Mail the completed application form in the envelope to:

Coordinator,LBSBIC

Lal Bahadur Shastri Institute of Management, Delhi

Plot No 11/7, Near Metro Station, Sector -11,

Dwarka, New Delhi-110070.

vi. The Group Discussion and Personal Interview will be held in Delhi.

vi Tick √ in the correct box properly

1.  Name: Mr./Ms………………………………………………………………………………………..(CAPITAL LETTERS) (As given in 10th Certificate)

2. Date of Birth…………………………………………………… …3. Sex :

3. Mailing Address…………………………………………………………………………………..

…………………………………………………………………………………………………….

……………………………………..Pin Phone Landline:………………...Mobile:…………………………

E-mail ………………………………………………. ………4. Permanent Address………………………………………………………………………………..

…………………………………………………………………………………………………….

……………………………………..Pin Phone………………………...

5. (i) Nationality…………………………………………… (ii) Domicile State…..………………….

6. Please tick mark : SC * / ST* / OBC * / KASHMIRI MIGRANT * / GENERAL(* Relevant certificate to be produced at the time of interview)

7. Category (Please tick any one)

(P.T.O.)

Male  Female

First GenerationEntrepreneur 

Family ManagedBusiness

Entrepreneur 

PotentialEntrepreneur 

Passport size photograph

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8. Details of Parents :

 Father’s Name………………………….…. Mother’s Name………………………………….

Occupation………………………………… Occupation………………………………………

Official Address………………………..… Official Address…………………………………

………………………………………….… ……………………………………………………...

 Phone/Fax………………………….. Phone/Fax………………………………………... 

9. Academic Qualifications

  EXAMINATION STREAM YEAR NAME OF SCHOOL/COLLEGE/UNIVERSITY BOARD/UNIVERSITY  

% OF 

MARKS 

OBTAINED

Std. X --

Std. XII (Arts/Science/Commerce)

Graduation

(B.A, BSc etc) Post 

-Graduation

  Any Other 

10. Work Experience, if any:

SELF EMPLOYED/ 

ORGANISATION 

WORKED WITH 

 DESIGNATION FROM TO MONTHLY SALARY /  

 ANNUAL TURNOVER

11.Write an essay of about 300 words each on “Why I want to start my own business” and “Where I want to be in the next 5 years”. Attach the essays (handwritten) along with the completed application form. Thesecond essay may not be submitted if you have GMAT/CAT/XAT/SET or any other equivalent score obtainednot earlier than the last two years.

 Declaration

I have read the information brochure and agree to follow all the terms and conditions given therein. All entries made inthis application form are true to the best of my knowledge and belief. I will produce original certificates at the time of interview. My candidature can be cancelled at any stage, if any information given is found to be untrue.

 Date…………………….. Signature of the Applicant  

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 For more information email at : incubation@lbsim.ac.in