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INDIAN INSTITUTE OF MANAGEMENT INDORE

Prabandh Shikhar, Rau-Pithampur Road, Indore 453 331 (M.P.) India


Tel: 0731-2439661-663, 2439400 Fax 2439660, 2439800 Email: eealumni@iimidr.ac.in

Executive Education Alumni Registration Form


{USE BLOCK LETTER ONLY}

Name

__________________________________________________________

Date of Birth ______________(DD/MM/YYY)

Gender - Male (

) Female (

Title of the Programme attended _____________________________________________


_______________________________________________________________________
Please select your exact title of programme attended as shown in your certificate. (MDP (
), INCOMPANY TRAINING PROGRAMME ( ), BBBEEP ( ), DEFENCE OFFICERS COURSE ( ),
FDP ( ), MEP ( ) please tick () the appropriate programme and enclose a copy of the certificate.

Batch year (Year of Participation) _____________________


Current Designation ___________________ Current Department ___________________
Current Organization ______________________________________________________
Current Industry -Please tick () the appropriate industry.
Academics
Advertising
Agriculture
Agriculture
Automotive
Consulting
Corporate Finance
Education
Engineering
Engineering

Entertainment/Media
Entrepreneur,
FMCG
Government
Hospitality
Industrial Marketing
Insurance
Internet
Investment Banking
IT/ITES

Logistics
Manufacturing
Marketing
NGO
Pharmaceuticals
Real Estate
Retail
Retail Banking
Telecom
Any other (please specify)

Preferred mailing address


Address1

___________________________________________________________

Address2

____________________________________________________________

Address3

____________________________________________________________

City

_______________

Tele No.

(STD Code) ____________ Tele No. ____________ Mobile No._______

Fax

_______________________Email________________________________

Pincode _______________ State _______________

About me:
You could include information such as past companies worked for and job profiles,
manta in life, your interest (in not more than 500 words).
Payment:
Please send demand draft / pay order of Rs.1,000/- (Rupees One Thousand Only) towards
one-time registration charges in favour of Indian Institute of Management Indore, payable
at Indore.
Payment details
Draft No.: ___________________Dated: _____________ Amount (Rs.)____________
Drawn on (Bank): _______________________________________________________

Important
Please enclose copy of your recent photo-identity document along with the form.

Date:__________________

______________________

Place: _________________

(Signature)

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