Application Form

User Id: 6003069

CANDIDATES ARE REQUESTED TO RETAIN THE PRINTOUT OF ACKNOWLEDGEMENT PAGE FOR FUTURE REFERENCE.

Personal Details

Name of Candidate: AKSHAY KHATRI

Father's/Husband's/Guardian's
JITENDRA KHATRI
Name :

Mother's Name: SHASHI KHATRI

Date of Birth: 15/Oct/1993 Candidate Gender: Male

State/Union Territory of
Category: General
Caste/Tribe:

Serial Number of caste/Tribe: Caste/Tribe Name:

Nationality: Indian Aadhar Card Number :

Person with Disability (PWD): No PWD Category:

Disability Percentage: Do you require wheelchair

support at the test centre?:
Would you be using a scribe for
the Test?: Would you be requiring the
Zoom Feature for the Test?:

Specific query on PWD Support:

Communication Address
OPPOSITE NEHRU MAIDAN

Address:

BEHIND PETROL PUMP

Country: India

State/Union Territory: ASSAM Other State/Union Territory:

District: Sonitpur Other District:

Town/City: TEZPUR Pin Code: 784001

Mobile Number: 8753813961 Email Address: akshay.khatri1@gmail.com

Mobile Number (Alternate) : 9957513199 Email Address (Alternate) : jitendrakumarkhatri@gmail.com

Exam Centre City Preferences
Preferred City 1: Dibrugarh

Preferred City 2: Guwahati

Preferred City 3: Shillong

Preferred City 4 Silchar

Academics Details

SSC/10th Std/Equivalent Details

Aggregate marks: 81.5 Month/Year of Completion: May 2010

Total Marks Obtained : 489 Maximum Marks : 600

SSC/10th Std/Equivalent Board Assam Board of Secondary Education

Name

HSC/12th/Equivalent/Diploma Course Details

Course Type: HSC Aggregate Marks: 71
Total Marks Obtained: 355 Maximum Marks: 500

12th/Equivalent Board Name: Assam Higher Secondary Education Council

Duration of Diploma Course:

University/Board/Other Authority
Name:

Discipline: Science

Month/Year of Course
Month/Year of Completion: June 2012
Commencement:

First Bachelor Degree Details

Are you in the final year of Bachelor Degree? Yes

I have more than one Bachelor's Degree?

Have you completed Bachelor

Total Duration of Degree: 4 Year
Degree?
Current Semester: Semester-7 Aggregate Marks: 60.25

Type of University/Institution:
State University

State/Union Territory Where Assam

University is Situated:
First Bachelor Degree Details

University Name: Dibrugarh

Name Of College: JORHAT ENGINEERING COLLEGE

Degree Name: BE

Discipline: Engineering/Technology

Month/Year of Course Probable Month/Year OR

August 2013 July 2017
Commencement: Month/Year of Completion:

Second Bachelor Degree Details

Are you in the final year of Bachelor Degree?

Have you completed Bachelor Total Duration of Degree:

Degree?
Current Semester: Aggregate Marks:

Type of University/Institution:

State/Union Territory Where

University is Situated:

University Name:

Name Of College:

Degree Name:

Discipline:

Month/Year of Course Probable Month/Year OR

Commencement: Month/Year of Completion:

Master Degree Details

Do you want to enter Master No
Degree Details?

Master Degree Completion Status: Duration:

Current Semester: Aggregate Marks:

State/Union Territory of
Type of University/Institution:
University:

University Name:

Name of College/Institution:

Degree Name:

Discipline:

Month/Year of Course
Month/Year of
Commencement:
Completion:
Other Professional Degree Details
Have you completed any professional degree such as CA/CS/ICWA
No
without completing Bachelor's Degree:

Professional Inter Marks: Professional Final Marks:

Month/Year of Course
Month/Year of
Commencement:
Completion:

Work Experience Details

Automobiles/Auto-ancillaries Banking/Financial Services

Durables Engineering/Industrial

Fast Moving Consumer Goods

Information Technology
(FMCG)

Pharmaceuticals/Healthcare Retail

Others
Telecommunications

Total Work Experience (In months 0

as on 31st July 2016)

Programme Details

Programme Names Interview City Selected / Not

IIM Ahmedabad PGP Kolkata Selected

(Interview City 1)

IIM Ahmedabad PGP

Delhi Selected
(Interview City 2)

IIM Ahmedabad PGP-FABM Kolkata Selected

IIM Ahmedabad FPM Ahmedabad Selected

IIM Amritsar PGP Kolkata Selected

IIM Bangalore PGP Kolkata Selected

IIM Bangalore PGP EM Bangalore Selected

IIM Bangalore PGP PM Delhi Selected

IIM Bangalore FPM Bangalore Selected

IIM Bodh Gaya PGP Kolkata Selected

IIM Calcutta PGP PGDM Kolkata Selected

IIM Calcutta FPM Kolkata Selected

IIM Indore PGP Guwahati Selected

IIM Indore PGP Mumbai Guwahati Selected

IIM Indore EPGP Kolkata Selected

IIM Indore FPM Indore Selected

IIM Jammu PGP Kolkata Selected

IIM Kashipur PGP Kolkata Selected

IIM Kashipur EPGPM Kashipur Selected

IIM Kashipur EFPM Kashipur Selected

IIM Kashipur FPM Kashipur Selected

IIM Kozhikode PGP Kolkata Selected

IIM Kozhikode FPM Kozhikode Selected

IIM Lucknow PGP Kolkata Selected

IIM Lucknow PGP ABM Kolkata Selected

IIM Lucknow PGPSM Kolkata Selected

IIM Lucknow FPM Lucknow Selected

IIM Nagpur PGP No Interviews for this programme Selected

IIM Raipur PGP Kolkata Selected

IIM Raipur PGPWE Raipur Selected

IIM Raipur EFPM Raipur Selected

IIM Raipur FPM Raipur Selected

IIM Ranchi PGDM Kolkata Selected

Kolkata Selected
IIM Ranchi PGDHRM

IIM Ranchi FPM Ranchi Selected

IIM Rohtak PGP Kolkata Selected

IIM Rohtak EPGP Guwahati Selected

IIM Rohtak FPM Rohtak Selected

IIM Sambalpur PGP Kolkata Selected

RGIIM Shillong PGP Kolkata Selected

RGIIM Shillong PGPEX To be decided Later Selected

RGIIM Shillong FPM Shillong Selected

IIM Sirmaur PGP Kolkata Selected

IIM Tiruchirappalli PGP Kolkata Selected

IIM Tiruchirappalli PGPBM Chennai Selected

IIM Tiruchirappalli FPM Trichy Selected

IIM Udaipur PGP Kolkata Selected

IIM Udaipur FPM Udaipur Selected

IIM Visakhapatnam PGP Kolkata Selected

Payment Details

Payment Mode Amount Payment Status Payment Transaction Number Order ID

online 1700 S GSM34757999243 600306920160916204124640

DECLARATION

I have previewed the Application Form by clicking on the Preview Application Button and confirm that all the data reflecting in the Preview are
correct. I hereby certify that the information given by me in this Application Form is true to the best my knowledge. I certify that I fulfill the
CAT 2016 eligibility criteria and undertake to produce original documents whenever necessary and I will not demand any reschedule of exam. I
agree to abide by the declaration of the authorities regarding the eligibility of my application and understand that any misrepresentation or
omission of facts in my application may justify cancellation of my CAT 2016 application & scores. I understand that all disputes will be subject
to the territorial jurisdiction of city of Bangalore only.
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