Indian Institute of Management,

Lucknow
Application for Executive Fellow Programme in
Management (2015)
IMPORTANT INSTRUCTIONS
Before filling this application form read the instructions and programme details
provided Online at http://www.iiml.ac.in (Executive FPM Announcement )
Fill in the Application Form in CAPITAL letters only.
A candidate is eligible to submit applications to a maximum of two areas. In such
cases, candidates who choose to apply to two areas are required to submit
separate application forms with all supporting documents, to be sent together
Please enclose copies of 10th, 12th and graduation, post-graduation mark sheets
along with each set of the form. Also enclose a copy of Scorecard of CAT / GATE /
GMAT / GRE, JRF/NET (UGC/CSIR) and IIM Lucknow WMP (Admission Test). If
short listed, all certificates (originals) should be produced at the time of interview.

AFFIX PHOTO
5cm*4cm WITH
WHITE
BACKGROUND

The form should be complete in all respects. Incomplete forms will not be
considered. Strike out whichever portion is not applicable.
Please enclose a Demand Draft of Rs.1000/-(Rs. 500/- for SC/ST
candidates)with the Application Form drawn in favor of INDIAN INSTITUTE OF
MANAGEMENT LUCKNOW payable at Delhi .This covers the application fee for
applying to two areas.

IMPORTANT ELIGIBILITY CATEGORY DETAILS

CAT

GATE

WMP Admission Test

Reg. No:

Reg. No:

Reg. No

Percentile

Percentile

Percentile

Score

Score

Score

Year

Year

Year

UGC JRF/NET

GMAT/GRE

Reg. No

Reg. No:

Year Qualified

Percentile

PGDM from IIMS/

AACSB/AMBA/EQUIS accredited
Institutes
CGPA

WMP/IPMX/PGPABM from IIMs/

AACSB/AMBA/EQUIS accredited
Institutes

Score

Course

Year

CGPA

AREA OF SPECIALISATION (Tick the relevant Box)

Agri-Business
Management
Finance & Accounting
Operations Management

Business Environment

Business Communication

Human Resources

Information Technology

Management

&Systems

Strategic Management

Sustainable Management

Decision Sciences
Marketing Management
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The completed application form must reach the EFPM Office, Indian Institute of Management Lucknow.B1, Sec-62,Noida
Campus,201307 India, latest by 28 February,2015
Page 1

PERSONAL DATA
Name (in capital)
Date of Birth
(dd/mm/yyyy)

Nationality
Category

SC

ST

0BC

PH

GEN

Gender

Male

Female

Marital Status

Married

Unmarried

Blood Group

CORESSPONDECE INFORMATION
Address1
Address 2
City

PIN

Phone/Mobile

Email

Academic Performance
Education
Stage

Name of theBoard/
University/Institute

Month & Year of

Examination
Month

Year

Subjects/
Specialization

Max.
Marks /
CGPA

% of
Marks/
CGPA
Obtained

Class/
Division
Obtained
(if any)

Secondary
School
Examination(10th)
Higher Secondary
School
Examination
(10+2)th

The completed application form must reach the EFPM Office, Indian Institute of Management Lucknow.B1, Sec-62,Noida
Campus,201307 India, latest by 28 February,2015
Page 2

Bachelors
Degree
Masters
Degree
Professional
Degree
(CA/ICWA)etc.
Any Other

Please account for break in your academic career, if any

_______________________________________________________________________________
_______________________________________________________________________________
Awards/Medals/Prizes/Scholarships/Certificates/Honors, etc. (Mention only those related
toAcademic/Professional Activities)
No.

Name of the Award

Awarding Institution

Year

1.
2.
Total Work Experience as on 30th June 2015 ________ years _______ months and
_____days.List all your work experiences in descending order (latest first) Use multiple
lines as needed.
(Do not include training, project work, work done as an integral part of curricular
requirement, and part time work):
Work Experience (Please mention full-time jobs only)
No.

Name of
Organization

Designation

Reporting to
(Designation)

Period

Nature of
Duties

From

To

Total
Experience
in months

Monthly
Salary

1.
2.
3.
4.
5.
6.
7.

Major Extra-Curricular Activities/Hobbies

Year
No.

Activity

Your Role

From

To

Total

Awards/Prizes/
Honors
if any

Remarks

1.
The completed application form must reach the EFPM Office, Indian Institute of Management Lucknow.B1, Sec-62,Noida
Campus,201307 India, latest by 28 February,2015
Page 3

2.

Annexure
Write a 100 word Annexure for each of the following and attach as separate sheets with this application

1.

Statement of Purpose

Describe your career goals and the reasons for your interest in the Fellowship
Programme in about 100 words.

2.

Previous Research Experience

Have you done any research project/experiment/field work as a part of your Masters
degree? Please write a brief summary of one such work in 100 words.

3.

Proposed Research Activity

This is not your research proposal. This is just your initial idea about the research you
want to understand doing your fellowship program.

Declaration
I certify that the particulars given by me in this form are true to the best of my knowledge and
belief. I know that at any time if the information furnished by me is found incorrect, my
candidature will be cancelled immediately.
Place
Date

Signature of the Applicant

The completed application form must reach the EFPM Office, Indian Institute of Management Lucknow.B1, Sec-62,Noida
Campus,201307 India, latest by 28 February,2015
Page 4